It’s easier than we think to put an end to this condition which affects 80% of the population and drives health care costs through the roof.
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Of all the punishments the heroes of Greek mythology were given, the giant Atlas was certainly handed down one of the most burdensome sentences. To get back at Atlas for going into battle against him, Zeus forced the god to carry the Earth on his back for eternity. Perhaps a dubious consolation for the poor Titan, but his story inspired the fathers of anatomy, who named the first cervical vertebra after him. The atlas vertebra carries the weight of the head and provides its mobility.
This small bone sits at the top of a pile of 24 joint-linked vertebrae which together form the vertebral column. This extremely sophisticated structure makes up the core of the skeleton, like a central mast for the human body. All the back muscles are attached to it, allowing the torso to move about and the entire body to remain upright.
“Today, we understand how the vertebral column and the structures surrounding it work,” says Viktor Bartanusz, head of the new Unit of Spinal Surgery at the Lausanne University Hospital (CHUV). “But we still don’t fully grasp the pain it causes. Certain spinal problems cause sharp pain in some people but no symptoms in others,” he says. “And even more puzzling is that some patients complain of back pain for years but have no organic cause. Does it come from the bones? Muscles? Discs? Ligaments? A wide range of theories is now being studied on the reasons for this ‘non-specific’ pain and how to relieve it, such as genetic predisposition or the exposure to vibrations at the workplace.”
Eighty per cent of the population in industrialised countries consults a doctor at least once in their life for pain in their lower back (lumbago), the middle of their back (dorsalgia) or their neck (cervicalgia). And the Swiss League Against Rheumatism says that 85% of that pain is not caused by a specific injury or disease.
The costs generated by back pain reflect how bad the situation is. In Switzerland, the Swiss Federal Statistical Office estimates that low back pain alone incurs costs representing between 1.6% and 2.3% of Swiss GDP, which equalled about 10 billion Swiss francs in 2005. That amount includes both direct costs for treat- ment and indirect costs due to work disruption. “Those are the most recent official figures,” says Iohn Norberg, from the Service of Rheumatology at CHUV. “But the percentage remains the same today, at about 14 billion.” Many measures have been taken to reduce these numbers. “We need to come up with solutions for economic reasons of course, but also to help people to regain an active social and professional life,” the expert says. “But to do that, patients must take care of their back (see point 1 below), and health professionals need to adapt by only providing care that is truly useful and beneficial in the long term.”
Doctors long recommended not doing exercise or carrying any weight, but the result of inactivity is that the muscles weaken and get to be out of shape. “Many studies have shown how effective physical activity can be,” the rheumatologist says. “Strengthening the back muscles provides better support for the vertebral column.”
The importance of staying active
In the past few years, a major change has revolutionised care for people suffering from chronic back pain not due to injury. No more forced bed rest. Physical activity is now highly recommended. “Anyone who doesn’t show signs of obvious trauma, such as a fracture or tumour, needs to stay active and use their back,” says Iohn Norberg. “For acute pain, inactivity is not recommended for more than three weeks.”
Exercise is an excellent way to relieve back pain, but also to prevent it,” says a study published in January 2016 in the Journal of The American Medical Association (JAMA). But what sport is best? “Everyone should choose an activity that they enjoy and that suits them,” Norberg advises. “Stéphane Genevay, a fellow rheumatologist from the Geneva University Hospitals (HUG), and I were involved in developing the website www.mon-sport.ch. In just a few clicks, users are given several ideas based on their abilities and what they enjoy doing.”
The fear of movement
It’s not just about muscles. Guillaume Finti, a physiotherapist registered with the Unit of Spinal Rehabilitation at CHUV, sees patients every day who have “kinesiophobia”, the fear of movement. “Some people stop moving for too long after experiencing acute pain and they end up afraid to move,” he says. “Unfortunately, that’s how acute pain can become chronic. What we do is help these people get over their fear.” The physiotherapist works with a team of ergotherapists, psychologists and rheumatologists to help people with kinesiophobia overcome their anxiety. “We offer a three-week treatment programme,” Finti says. “Patients spend 35 hours a week doing physical exercises as a group and individually, receiving care and advice. In most cases, we manage to rebuild their confidence in their abilities, which gradually leads them to start moving again, experience their pain differently and resume professional activity.”
Iohn Norberg points out that this type of programme has been available for several years. “This type of care should be offered on a wider scale, and all doctors, both with public and private institutions, should encourage patients to move more in their daily lives. That’s certainly less profitable than regular cortisone injections or other repetitive treatments, but physical activity remains without a doubt the best long-term remedy.
Starting in the teen years, the structures of the vertebral column gradually begin to experience wear and tear. Disc degeneration is when the intervertebral discs show clear signs of wear. These thin cartilaginous structures play a vital role as shock absorbers. Over time, the discs dry out and lose their elasticity and their resistance to pressure. They naturally become less flexible and more brittle. Disk tears can result in a compressed nerve root. This is called a spinal disc herniation, which can become painful if inflamed.
A study by the Occupational Health and Safety Research Institute (IRSST) in Canada establishes a direct link between back pain and occupational stress. When under constant pressure, the muscles— especially those in the shoulders and neck—cannot relax, storing toxins and becoming painful. Other negative emotions such as anxiety and nervous tension are also responsible for making pain chronic. The expression to lift or have a “weight off your shoulders” appropriately refers to being relieved of a burden, concern or a trouble after some time.
Several studies have shown that excess weight accelerates degenerative disc disease and puts pressure on joints between the vertebrae, causing ligament pain and muscle degeneration. Overweight people often suffer from back pain. Another category of the population seems increasingly affected—children.
A study published in the “Journal of the American Academy Of Orthopedic Surgeons” in January 2016 reported that one out of three adolescents have back pain. Child obesity and wearing heavy backpacks are suggested to be the causes of pain and deformation in the vertebral column.
All research into the causes of back pain point to sedentary lifestyles. Inactivity weakens the muscles in the back, passing on the support function of these muscles to the vertebral column and making it more vulnerable to injury. This problem concerns all segments of the population, from the elderly to children, including those actively employed who sit for long hours in front of their screens. A study by the Swiss Federal Institute of Technology in Zurich shows that standing for long periods also causes muscle fatigue. After several days it can lead to musculoskeletal disorders and back pain.
Progress for surgery: Less but better
New mindset is also emerging about back surgery. Patients should only have surgery if the anatomical cause of the pain has been specifically identified and can be treated with a surgical procedure. In its Smarter Medicine campaign launched in 2014 to limit unnecessary procedures, the Swiss Society of Internal Medicine also advises against X-rays for patients experiencing low back pain for less than six weeks if they show no other alarming signs (read our report on the “Less is more” movement on www.invivomagazine.com). “Any image of such a complex structure can show a small, harmless abnormality,” says Iohn Norberg. “Is that the cause of the pain? Often, we have no idea! The patient might end up focusing on it, whereas with a bit of patience and physical activity, the pain would disappear on its own.”
“People are in so much pain that they ask us to operate, even if they have no serious pathology,” says the neurosurgeon Viktor Bartanusz. “As specialists, we must study the test results and decide whether the operation would be useful. If surgery won’t help or risks making the pain worse, we have to be able to say no. Only 10% of people with back pain really need an operation.”
This less-is-more approach is not yet systematically applied by professionals or taken into adequate consideration by researchers. Viktor Bartanusz takes an example from the study conducted by the Department of Neurosurgery at the University of Texas reported in the scientific publication The Spine Journal in 2013.
“It shows that between 1993 and 2012 the number of trials performed to compare the choice of surgical instruments far exceeded the number of trials to determine the effectiveness of surgery,” the expert laments.
More precision, more reliability
When dealing with certain organic causes of back pain, such as a tumour or fracture, surgery is in fact likely to improve the patient’s health. “Tremendous technical advances have been made in recent years,” says Viktor Bartanusz. “With smaller instruments and ever more accurate imaging, surgery is being optimised and becoming more precise. Statistically speaking, it is now safer to have herniated disc surgery than to drive on the motorway!”
Viktor Bartanusz predicts another change over the next ten years. “Orthopaedic surgeons will work jointly with neurosurgeons on spinal disorders. These two specialities will eventually become one and further improve the quality of our surgical procedures.”
Growing use of robotics
In the future, back surgeons will increasingly benefit from the assistance of robots. In December 2015 at the Amiens-Picardie University Hospital in France, a robotic surgery system developed by the French company Medtech was used to operate on a herniated disc for the first time. The Rosa Spine machine features an articulated arm guided by the surgeon for greater safety and dexterity in movement.
The Lausanne-based company KB Medical is also pre- paring for the commercialisation of its spine surgery robot AQrate. “We are currently in talks with large distributors in Germany and the United States,” says the CEO Jean-Marc Wismer. “Minimally-invasive, robot- assisted surgery is used to make smaller, more precise incisions. That means that the patient recovers more quickly. And in general, the risks that can occur during surgery are reduced.”
Hight-tech innovations, smart T-shirts and back pacemakers
The “back pain market”, with its many potential customers, has sparked innovation from start-ups to develop ways of relieving pain. The Paris-based Percko attracted a lot of attention with its sensor-embedded T-shirt that corrects poor posture. This lightweight garment fits like a second skin and alerts its wearers when they start to slouch, encouraging them to adjust their posture with its string of tensors fastened into the fabric along the spine, shoulders and thorax. “We hope to sell 10,000 shirts in 2016 to bring in about €1 million in revenue,” say Quentin Perraudeau and Alexis Ucko, the two young engineers who launched the project.
The target seems feasible as the Percko T-shirt, sold at €129 apiece online and at selected points of sale, garnered immediate interest. By the end of 2015, the start-up had raised more than €385,000 pledged by 3,325 backers on the crowdfunding website Kickstarter. Backers include ten or so companies that view the product as a useful tool to improve their employees’ well-being.
The posture of employees, sitting physically inactive for long hours in front of their screen, is often called out as one of the main causes of back pain. “In a seated position, tension increases in the deep muscles of the spinal column and puts pressure on intervertebral discs,” says the posture therapist Olivier Girard, head of the Ergonomics Services Unit at the Institute for Work and Health of French-speaking Switzerland (Institut universitaire romand de santé au travail or IST) in Epalinges. The expert believes it is essential for people to sit in a comfortable, ergonomic position (see opposite). “It’s not enough to protect your back,” he adds. “After 30 or 40 minutes, you need to change position. That doesn’t mean stop working. Consider making a phone call while standing, printing a document on a machine a few metres from your desk or going to see your co-workers nearby rather than writing an email or calling them.”
The Irish company Mainstay Medical developed a system, ReActiv8, to relieve chronic low back pain. The implant works like a pacemaker, with two electrodes placed on either side of the vertebral column. The electrodes are connected to a device that sends out small electric impulses to stimulate the nerves responsible for contracting the key muscles that stabilise the lower back. Mainstay Medical announced positive results to its clinical trials and plans to initiate the commercialisation phase shortly.
“That’s great if these innovations relieve pain,” says the rheumatologist Iohn Norberg. “But we shouldn’t rely on these devices and forget the most natural and most effective way to prevent and treat back pain. Moving!” ⁄
The percentage of the Swiss population that suffers from back pain between once a year and several times a week.
In millions, the number of Swiss people unable to work for several days or weeks a year due to low back pain.
In millions, the number of days per year Swiss people take leave, unfit to work due to back pain.
Source: Report, Le dos en Suisse 2011 (The Back in Switzerland), by the Swiss League Against Rheumatism.
A mattress that is too firm can cause stress for the vertebrae. But a mattress that is too soft fails to support the body adequately. If the shoulders and hips dip into the mattress, the spine is arched. The best option is a mattress that is neither too firm nor too soft and can support and relax the back.
85% of pain is “non-specific”, meaning it is not due to any particular organic cause such as a fracture, tumour or inflammation. If it’s not related to an injury or disease, this is good news.
Taking anti- inflammatory drugs for acute pain can o er relief within a few hours. However, medication should not be the only treatment. It is merely a temporary remedy. For people who are inactive for long periods of time or do not do enough physical exercise, the discomfort is likely to come back. As soon as the pain subsides, people should take care of their backs by staying as active as possible
There are a number of strength training exercises to build muscle in the back. Strengthening the core targets deep muscles and, when practised properly and regularly, guarantees results. The classic version involves facing the floor with your body weight distributed between the tips of your toes and your forearms bent at a 90-degree angle to the shoulders. The longer you hold the position, the more muscle you build.
Before beginning any activity that will put strain on your back – be it gardening, ironing or of course muscle building – you should warm up your back muscles. Kneeling on all fours with your hands resting on the floor, switch from a rounded back to an arched back about 30 times. Keep your head aligned with your spine so it can follow the movement.
The back muscles must be relaxed regularly. For example, to relax the lumbar region, lie down on your back with your legs elevated and bent onto a structure, such as a stool. The arms should lie alongside the body with the palms down. This position is beneficial because it takes all pressure o the back. The tilt of the pelvis stretches the lumbar muscles and removes any tension.
Remaining seated for many hours in front of a screen can cause muscle contractions. Your heels should be placed under your knees (legs should not be crossed) with the lumbar region resting firmly against the back of the chair and the weight of the body on the ischia bones that make up the lower pelvic region. The middle of the back is naturally slightly forward. The shoulders are relaxed and the elbows free. It is also highly recommended to get up and move around regularly.