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Your guide to positively managing back pain step

The MBF Back Pain Management Program

The MBF guide to positively managing back pain is for adults with back pain, or the parents of children with back pain. Based on current research, it offers practical advice and information to help you better control your back pain and make the most of life.

The guide is part of the MBF Back Pain Management Program, one of the programs MBF Health offers at no additional cost to help members with MBF hospital cover to better manage their health conditions.

The program enables members to access tools and resources such as:

an MBF Back Pain Action Plan that you can take to your doctor to fill in together (you will find it at the back of this guide) along with some background information on what back pain is and how to reduce its impact on your health and everyday living; specific information about back pain; and a professional nursing telephone service trained to answer your queries on general health.*

*Operated by ETI Australia Pty Ltd, trading as Mondial Assistance.

Contents

The MBF Back Pain Management Program 1

What is back pain? 3

Why do I need an MBF Back Pain Action Plan? 7

How is back pain managed? 7

The MBF Back Pain Action Plan 17

Where can I get further information? 19

The information provided in this brochure is not intended to be a substitute for the advice of your personal physician or other qualified health care professional. The mention of specific products or services in this brochure does not constitute or imply a recommendation or endorsement by MBF unless it is specifically stated. MBF does not recommend or endorse any specific tests, doctor, specialist or other health care professional, products, procedures, opinions or other information that may be mentioned in this brochure. Reliance on any information provided by MBF in this brochure is solely at your own risk.

If you think you have a medical or psychiatric emergency, call 000 or go to the nearest hospital. If you are not sure what sort of care you need, please call your doctor or local hospital.  There are a number of products and services mentioned throughout this brochure for which MBF does not pay a benefit such as some doctor consultations and some complementary therapies.  The information in this brochure relates only to the particular MBF Positive Health Program in question and does not represent which products and services may or may not be covered under your level of MBF cover.  The information provided in this brochure is current and correct as at 1 April 2007.

Remember, following a written MBF Back Pain Action Plan that’s been developed especially for you can significantly reduce the long-term effects of back pain. It often takes several visits to your doctor to work out the best Action Plan for you and to review how well your medication and lifestyle changes are working. The Plan may also need adjusting over time.  So take this guide with you when you next visit your doctor so you can get started on making your own MBF Back Pain Action Plan together – and enjoying life, even with back pain.

Note: MBF does not pay any benefits for doctors’ and specialists’ services provided outside of hospital unless we specify otherwise under your level of cover and we have an agreement with the provider for that treatment.

What is back pain?

Back pain affects up to 30% of Australian men and women.  Often there is no easily recognised cause, however we do know how to manage and control many of its effects, which is what the MBF Back Pain Management Program is all about. In this guide you will find some suggested steps you can take to help lower the risk of back pain, reduce the number of recurrences and limit the pain caused by chronic back pain. There are two main types of back pain:

1.  Acute or short-term back pain is the common type, and usually resolves itself in three days to six weeks, whether or not you have treatment. 

2.  Chronic back pain exists if pain and symptoms persist for longer than three months.  It can be useful to know when you need to seek medical help and when self-care alone will probably work for you. If you are still unsure, your doctor can make that assessment and guide you through your treatment and recovery.

Anatomy of the back

Your back is involved in almost every move you make. It performs a lot of ‘unseen’ and ‘unfelt’ work, which makes it particularly vulnerable to injury. Your back is in action whether you are walking, standing, lying, sitting or balancing, holding your posture or your position. While pain or discomfort can occur anywhere in your back, the lower back is the most common source of back pain because it supports most of your body’s weight.

Your spine is comprised of 25 bones called vertebrae, stacked on top of each other, resting on the pelvis (your hips) and topped by the skull. Between each pair of vertebrae is a tough, spongy cushion called a disc. These discs act as shock absorbers as well as providing for movement of each vertebra in relation to the next, and give the spine its flexibility. Strong elastic ligaments hold the vertebrae and discs firmly together in a column called the spinal column.

The spine also provides a protective case for the spinal cord that runs from the brain, by way of a canal through the middle of the vertebrae down to the lower back. The spinal cord forms the main communication channel between the brain and the rest of the body via the nerves that branch off at intervals through spaces between the vertebrae.

Causes of back pain

Most back pain can be called ‘simple back pain’ and is caused by strains and minor injury. Although the pain comes on quickly and can be triggered by a particular movement, the cause may have been building up for some time. A specific diagnosis may not be necessary in order to treat and manage simple back pain effectively.

There are many causes of back pain as described below.

However, it is important to note that people without any symptoms of back pain can also have findings on x-ray such as osteoarthritis, lumbar spondylosis (degeneration of the lower spine) and spinal canal stenosis. Therefore the findings can be inconclusive as they may show up some other findings but may not detect the cause of the pain. Possible sources of back pain include the following:

Lumbar muscle strain is the most common cause of low back pain and usually resolves itself completely within a few weeks.

Muscle spasm occurs when very tense muscles remain contracted (as in cramp) and can even tear the muscles or ligaments supporting the back.

Degeneration of the discs or discogenic back pain is the result of damage or wear and tear to the intervertebral discs.

It should not be confused with disc herniation, which is described below.

Ruptured or herniated disc occurs when a disc degenerates due to wear and tear or damage through injury or ageing, and then partially ‘herniates’ or pops out of place into the spinal canal. If the herniated disc protrudes in a way that puts direct pressure on the nerves, it can cause pain radiating down the leg, sometimes into one or both feet. This type of pain is known as sciatica. Most disc herniation occurs in the lower back.

Sciatica arises when ‘slipped’ or herniated discs bulge and press on the nerves as they branch off from the spinal cord on their way to joining together to form the large sciatic nerve.

This pressure irritates the nerve, causing pain from the lower back radiating down the leg. This pain is known as ‘referred pain’ because it is caused by pressure or injury in one place (the spine) but actually felt in another place (the lower back, buttock and thigh or even the feet and toes). It usually affects one limb. Sciatica is not always caused by a particular event or injury, but may be the result of general wear and tear on the structures of the lower spine. The vast majority of people with sciatica get better over time and find relief from pain with non-surgical treatments.

Arthritis may affect the vertebrae and the joints between them, setting off inflammation and deterioration, which causes pain in the joints. If you have arthritis in your spine, you may experience back pain, especially when you make certain movements.

Spondylolithesis occurs when adjacent vertebrae become unstable and ‘slip’ in position slightly over or under each other.

The most common cause of spondylolithesis is degeneration of the stabilising structures such as the discs, bones or ligaments in the spinal column.

Spinal stenosis is the narrowing of the spinal canal, through which the spinal cord passes, where the spinal canal becomes constricted due to arthritis or other conditions in the aging process. If the spinal canal becomes too tight for the cord, back pain and symptoms of nerve damage can result.  Spinal curvatures (such as kyphosis) are usually noticed in children or teenagers but are sometimes not identified until adulthood. They may be inherited or arise from many other causes, and can often get worse over time.  Other conditions can cause back pain such as fibromyalgia, which is a chronic disorder and is characterised by widespread musculoskeletal pain, fatigue and multiple tender points in the body.

Why do I need an MBF Back Pain Action Plan?

As yet there is no cure for chronic back pain, however, there are many ways to manage the pain and reduce the impact of back pain on your life. A combination of medical advice, medication, physical exercise, therapies and a positive mindset can help you deal with back pain effectively. An MBF Back Pain Action Plan, like the one at the back of this guide, developed with your doctor, can help you stay on track and manage your back pain so that your health and lifestyle will benefit.

How is back pain managed?

If you have experienced back pain for more than a few weeks, you may need to have your pain assessed and find the right form of treatment. It’s best to visit your doctor to rule out any serious causes of back pain and get a correct diagnosis.  The doctor may do a physical examination including:

*        lifting your legs straight up while you’re lying down to see if it causes pain;

*        moving your legs in different directions and to different positions;

*        testing your nerve function using a rubber hammer to check your nerve reflexes; and

*        touching your legs in many locations with a pin, cotton swab or feather to test your sensory nervous system.

Your doctor may do further physical tests such as:

*        x-rays;

*        magnetic resonance imaging (MRI);

*        computerised image of the spine scan (CT); and

*        blood tests for other conditions that can affect your spine such as some forms of arthritis.

X-rays of the spine are not always recommended for non-specific back pain, especially if the pain is due to muscle or ligament strain.

Seeking medical advice

Although most back pain is resolved completely within a few weeks, it is important to stress that it can still be caused by a more serious underlying disease. So, if you experience any of the following, please see your doctor immediately:

*        pain caused by an injury or fall, which may indicate a fracture (especially if you have osteoporosis);

*        difficulty in controlling your bowels or bladder;

*        fever, chills, sweats or other signs that may be the result of an infection;

*        unexplained weight loss before or around the time of the back pain;

*        pain that is so intense you can’t move around;

*        numbness in your leg, foot, groin or rectal area or a feeling like ‘pins and needles’;

*        pain going down your leg to your thigh or below your knee;

*        pain that doesn’t improve after two or three weeks;

*        pain that wakes you up at night;

*        pain that does not respond to simple treatments;

*        pain causing you to take painkillers continuously for more than a few days;

*        if you have cancer or a strong family history of cancer; and/or

*        if you are aged over 65 and have not experienced similar back pain before.

These symptoms could signal nerve damage or other serious medical problems and need to be investigated as soon as possible. The best advice is to have the cause assessed and get a correct diagnosis so that you can find the right treatment and pain relief. If the cause is specific, it is advisable to work out the best treatment with your doctor. However, if the cause is non-specific, you can start to use your MBF Back Pain Action Plan now.

Treatment for back pain

Early back pain management While back pain can have a negative impact on your life, we provide information that may help you manage pain and develop a positive approach to your wellbeing.

If your back pain has recently commenced or is affecting your lifestyle, there are some measures you can take that may alleviate the pain.

These include:

Ice and heat – try an ice pack for the first 48 to 72 hours.

Then use a heat pad.

Activity and rest – stop any physical activity for the first few days, to reduce inflammation and relieve the symptoms, especially if the pain is due to muscle strain. In severe cases, bed rest may be required, however prolonged periods in bed can cause symptoms to persist and there is evidence that this can be harmful. Avoid any heavy lifting or twisting your back for six weeks after the onset of pain.

Medication – anti-inflammatories such as ibuprofen (brand names Nurofen and Brufen) are widely known and used in back pain. In addition to pain relief, they also reduce inflammation around the affected areas such as muscles, joints or ligaments. If taken regularly for a few days they can be effective in reducing pain in the medium term.

However, known side-effects include gastro-intestinal bleeding, so these drugs should only be taken under the direction of your doctor if you have stomach ulcers or a similar condition. Paracetemol (brand name Panadol) is also effective in pain relief and does not aggravate a stomach condition. Remember that trying to avoid medication can force you to hold yourself stiffly or move in an unnatural way, which creates a cycle of pain, making symptoms worse and prolonging the episode.

The medication information outlined here is for general explanatory purposes only and is not medical advice.

You should always check with your doctor prior to taking any medication.

Sleeping position – try sleeping in a curled-up foetal position, with a pillow between your legs. If you sleep on your back, place a pillow or rolled towel under your knees to ease the pressure on your spine.

Exercise – keeping fit is important, so maintain your exercise program, beginning with light cardiovascular training, walking or swimming. This will boost the blood flow to your back and promote healing.  Stretching and strengthening exercises are also helpful in improving stability and protecting your back in the long term.  However, starting too soon after an injury can prolong the pain.  If you are unsure, your doctor or physiotherapist can help you decide when you should begin exercising and help you choose an exercise program that works best for you.

Long-term back pain management

Exercise Physical activity is an essential part of any back pain management program. Try to exercise every day, even for a 30 minute session. In your weekly program include two sessions of mobility and strengthening exercises for key back muscle groups. Also, include some cardiovascular exercises for your heart and lungs. However, don’t push your body too far. If you still feel pain two hours after exercising, it’s a signal that you have been doing too much or you may be doing the wrong type of exercise.

Mobility exercises are referred to as ‘range of movement’ or ROM exercises of the joint. With these exercises, you move your joints as far as they can comfortably move in each direction. The goal is to decrease stiffness and pain while maintaining flexibility and improving joint function.

There are two types of strengthening exercise — isometric and isotonic:

1.    Isometric exercise is a system of physical exercises in which muscles are caused to act against each other or against a fixed object.

2.    Isotonic exercises involve moving your joints.  They are similar to mobility exercises and will strengthen the muscles especially if you perform them in water, which offers some resistance, or if you increase the number of times they are performed.

Cardiovascular exercises are endurance exercises which increase your overall fitness by improving your heart and lung function as well as circulation. The most beneficial exercises are often simply walking, cycling and swimming. These work to strengthen muscle groups and improve cardiovascular fitness while minimising the impact on your joints.

ó Pain management programs

If your back pain is not resolved in the short term, a pain management program may help you to get back on track.

You can learn how to manage your medication, develop coping strategies and improve your wellbeing. A clinical psychologist, trained in cognitive behavioural therapy (CBT), can help you build confidence and overcome any obstacles to your recovery. If you think this might promote your recovery, ask your doctor for a referral.

Other therapies

Your physiotherapist or personal trainer may be the right person to advise you on the type and level of activity that’s best for you. Develop an exercise program to increase strength and flexibility in your back muscles and work with them to achieve some daily activity goals. Your physiotherapist may also advise you on other physical therapies including heat, ice, massage and ultrasound that may also provide supplementary pain relief.

Referral to a specialist

If your pain lasts longer than six weeks, visit your doctor to discuss a referral to an orthopaedic surgeon (bone specialist), a neurologist (nerve specialist) or a neurosurgeon.

Surgery

Hospitalisation, traction or spinal surgery are usually a last resort where there is nerve damage or prolonged back pain.  Make sure you have a good understanding of the reasons for surgery and the probability of improved pain relief.

It’s also important to discuss the risks as well as any potential unfavourable outcome. Not all back problems are easily resolved by surgery. In some cases, surgery can be less successful than others. A second opinion is sometimes useful to resolve or clarify any issues or concerns you may have.

Complementary therapies

Complementary therapies are used for many conditions, including back pain. If you want to consider this option, make sure you obtain accurate information and make the decision in conjunction with your doctor.

Chiropractors

Chiropractic manipulation is a technique of spinal adjustment that chiropractors believe ‘corrects’ parts of the spine or joints to restore ‘normal’ motion in the back that can relieve pain.

Osteopathy

Osteopathy involves manipulation of the skeleton and muscles to promote mobility and balance. Osteopaths believe that a healthy body relies on a structurally sound musculo-skeletal system and that only when the bones, joints and muscles are working smoothly and harmoniously, can the other systems of the body function at their best.

Acupuncture

Acupuncture involves inserting very fine needles into precise points of the body for 20–40 minutes. It stimulates nerve endings that transmit signals to the brain, activating the pain control centre in the body and triggering the release of endorphins, the body’s natural pain killing chemicals.

Yoga*

Yoga teaches us the importance of slowing down and listening to the body’s messages. Through postures and slow movements, yoga can help back pain sufferers by stretching and strengthening key muscle groups. Yoga promotes wellbeing by helping the body unwind, stilling the mind and helping to achieve mental focus. It also enhances awareness of the ways we may be contributing to our own pain.

*MBF will only pay a benefit for yoga classes where the yoga program is intended to prevent or relieve a specific health condition or conditions and an MBF Living Well approval form signed by your doctor or MBF recognised provider is submitted.

Back pain prevention

There are ways to avoid damaging your back, although some back pain cannot be prevented. Being aware of situations where your back is at risk of injury may help to prevent any damage to your back.

The risk of back pain is highest if you are overweight, you’re a smoker or you are pregnant. You are also at risk if you have bad posture or if there is a family history of back problems.

People who suffer from arthritis or osteoporosis are also in the high-risk category. When you are not exercising or you lift and carry without due concern for the correct posture, you are putting yourself at risk of back strain. Being stressed or depressed can also make you vulnerable to pain and injury.

The skeleton and muscles normally work smoothly together, however, if your job requires lifting and carrying heavy items, you are advised to take the relevant precautions. You can lessen or perhaps avoid back pain by improving your overall level of fitness and learning how the body works and how to move heavy objects safely. So take care of your back, don’t take risks and follow the guidelines for back pain prevention provided overleaf.

Guidelines for back pain prevention1

Exercise.

Regular low-impact aerobic activities that don’t strain or jolt your back can increase strength and endurance in your back and allow your muscles to function better.

Walking and swimming are good choices. Talk with your doctor about which activities are best for you. It is important to exercise regularly because an inactive lifestyle contributes to lower back pain. Abdominal and back strengthening exercises help condition the muscles so they work together like a natural ‘corset’ for your back.

Maintain a healthy weight. Being overweight puts strain on your back muscles. If you’re overweight, trimming down can reduce the chance of your getting back pain.

Improve your posture during the day and adjust your sleeping position until you feel comfortable.

Avoid standing for long periods of time, but if you need to, try using a stool at regular intervals. Rest each foot on the stool alternately.

If you must sit at your desk or at the wheel of a car or truck for long hours, break up the time with time out to stretch. Bring your seat as far forward as comfortable to avoid hunching.

When sitting at work, especially if using a computer, adjust your chair to your body size. The back rest should support your lower back and your feet should comfortably rest on the floor with ankles and knees at right angles.

Place a small pillow or rolled towel behind your lower back while sitting or driving for long periods of time.

Avoid wearing high heels and use cushioned soles when walking.

Don’t slouch as poor posture puts a strain on your lower back.

Choose a firm, supportive mattress with no ‘valleys’.

Quit smoking as it is linked to back pain and may reduce pain. It will also lower the risk of heart disease, cancer and other diseases.

Try practising relaxation techniques such as yoga and tai chi* or have a massage.

Keep a positive attitude about your job and home life. Studies have shown that people who are unhappy at work or home

tend to have more back problems and take longer to recover.

* MBF does not pay benefits for tai chi.

1. Australian Physiotherapy Association, www.physiotherapy.asn.au

2. Montefiore Patient Health Education Center, www.montefiore.kramesonline.com

Lifting guidelines for back safety2

Whether you have chronic back pain or a healthy pain-free back, it is most important to lift heavy objects in a safe and supportive way. Follow these tips to prevent injury to your back:

Plan

Plan what you want to do and don’t hurry.

Separate your feet shoulder-width apart to give you a solid base of support.

Bend at the knees. Maintain the natural curve of your spine; don’t bend at your waist.

Tighten your stomach muscles.

Position

Position the object close to your body before lifting.

Lift with your legs, not your back. Bend your knees until you are in a squatting position and then straighten at the knees – don’t bend at the waist.

Push rather than pull when you need to move heavy objects.

When appropriate, use an assistive device such as a transfer belt, sliding board or draw sheet to move heavy objects or people.

Avoid

Avoid trying to lift something that is too heavy or an awkward shape on your own. Seek help.

Avoid twisting your body. Instead, point your toes in the direction you want to move in and pivot in that direction.

The MBF Back Pain Action Plan

Take this Action Plan with you when you next visit your doctor and ask your doctor to fill in the review dates and actions required. You can then use it to help keep yourself on track – so you can stay active and well for longer.

Goals to be reviewed Action Review dates due

Acute back pain (symptoms resolve within 6 weeks)

Positive mindset Keep positive and expect recovery within 3 to 6 weeks.

Manage pain

For first 48–72 hours – use ice; After 72 hours – apply heat;

Take pain relief.

Avoid prolonged bed rest Take bed rest for a maximum 1–3 days.

Progressively increase activity Get back to a regular routine and work if possible.

Manage ongoing pain

Review with doctor and follow specific instructions; visit your

physiotherapist or health professional; take breaks regularly; go for short walks; Improve posture.

Return to work Plan for return to work with your doctor and employer.

Chronic back pain (symptoms persist beyond 3 months)

Positive mindset Keep focused on a positive outcome.

Manage persisting pain

Take pain relief as required; refer to multi-disciplinary pain management clinic if necessary.

Keep active.  Develop fitness program; walk, cycle, swim for a minimum 30 mins per day; commence strengthening program.

Modify lifestyle habits Correct lifting techniques; Improve posture; Check ergonomics.

Manage weight Improve diet; manage weight; maintain exercise routine.

Learn relaxation Practice yoga, tai chi, pilates or other relaxation techniques.

Quit smoking Give up smoking.