Grahame Brown is a physician who qualified from the University of Bristol in 1979. After junior doctor hospital jobs in the NHS, he served five years as a medical officer in the Royal Air Force. On leaving the armed forces, he worked as a GP in Norwich for five years and then as a GP in Birmingham for six years. Throughout his time in general practice he developed a special interest in, and acquired postgraduate qualifications in musculoskeletal, sport & exercise medicine, occupational medicine, psychological and behavioural medicine. In 1996 he left general practice to develop a musculoskeletal, sport & exercise medicine service at the Royal Orthopaedic Hospital NHS Trust in Birmingham, where he continues to work as a specialist physician within a large multidisciplinary team. He has tutored many one-day courses throughout the UK and Ireland, for professionals from all disciplines, on psychological approaches to accelerate healing and treating pain utilising the principles taught by the Human Givens College. He has contributed to textbooks on musculoskeletal medicine and occupational medicine and published a book in 2009: Liberate Yourself from Pain: A Practical Guide for Sufferers.
No drugs – No surgery – No more anxiety.
Persistent back pain has very little to do with ongoing physical injury, and in order to beat the pain you need to understand what’s causing it. The BPS method uniquely looks at how your body processes pain and physical triggers (Bio-), what exactly your pain is (Psycho-) and how to change the environmental factors that contribute to your back pain (Social-). Combined they are the key to your recovery.
Refined by the team at the world-renowned Royal Orthopaedic Hospital in Birmingham – the UK’s leading back-pain clinic – the Biopsychosocial approach will transform how you think and feel about back pain, and what you do about it. Back to Life is the lasting solution you’ve been waiting for.
LOW BACK PAIN is one of the biggest threats to a good quality of life. It causes a range of dysfunction and disability and is poorly understood by many, including those within the medical profession. Being pain-free is seen as the goal but this can be elusive, with modern medicine seeming unable to offer a solution for most patients. Spinal surgery is, in fact, very rarely indicated for non-specific low back pain and, when undertaken, is often disappointing, with most patients continuing to experience some degree of pain and usually still requiring painkillers.
As with many things, understanding a problem makes it easier to tackle. The spine is a complex structure in itself, and when addressing back pain it is also essential to understand the complexity of pain and its interactions. There is indisputable evidence that addressing the physical and psychological aspects of pain together is far more effective than treating one or the other in isolation.
Grahame Brown and David Rogers have many years’ experience in managing patients with spinal pain, both individually and as part of an interdisciplinary team. They have honed techniques that help patients to identify and modify the beliefs and fears that have added to functional restrictions, whilst at the same time helping them to improve physically. The results obtained have been impressive and are published in medical literature. Their combined ‘biopsychosocial’ approach addresses the range of issues that contribute to the pain experience, and gives patients skills that will continue to be useful should symptoms recur, so they are less likely to require medical input subsequently, and more likely to retain function. Patients may feel uncomfortable addressing some aspects of this approach, or worry that considering the psychology of pain implies that ‘their pain is in their head’. This book explains that is not the case, but instead that pain is in some ways a bully, with no respect for age, gender, social status or any other marker of identity. Bullying does not exist in a single form. Physical bullying has psychological effects, and psychological bullying has physical consequences. Back pain is very much the same.
What is essential when patients are trying to recover from back pain is that they participate actively in the treatment plan and work with the treating team. What is set out in the pages that follow is a guide to how back pain arises, how it can be managed, and which symptoms are, and are not, worrying. Not everyone will benefit but those who read with an open mind, are honest with themselves, have realistic expectations, and engage with the approach are well placed to have a good chance of seeing their quality of life improve.
Perhaps the most important part – as with all treatments – is durability. Does any treatment last? The natural history of back pain is variable, and patients may be at risk of further exacerbations in future. Effective treatment therefore needs not only to address the current symptoms, but also to give patients the tools with which to manage their backs going forwards, both during good periods and during exacerbations of pain. The biopsychosocial approach has significant advantages over more medicalised treatments, such as surgery or injections; these are reactive, they are not appropriate early in the course of an episode, and patients may tend to relapse more quickly and be unable to self-manage effectively.
I commend this book to you to as a tool that may help now and will also be useful to refer back to in the future.
Mel Grainger FRCS (Orth)
Consultant spinal surgeon
MOST OF US have experienced an episode of back pain at some point in our lives. More often than not it will settle within a few hours, or cause us trouble for a few days, then disappear without trace. Sometimes it may last for a few weeks, and we might consult a variety of healthcare professionals before, in time, the symptoms settle and life returns to normal. We may need to take some medication to help us for a short while, and we could be given lots of different explanations of why our backs hurt, but usually the pain does not make a significant difference to our quality of life in the long term.
However, you are probably reading this book because your back pain has persisted long beyond what you expected. It may be that those tried-and-tested treatments you took in the past, that previously worked so well, no longer help you. Back pain may have stopped you enjoying your interests or sport, or it might be preventing you from doing your usual job. You could even have withdrawn from social activities because you find it difficult to predict when you are going to have another bad day, so you’ve stopped making plans.
Living with unrelenting back pain depletes your physical and psychological resources; it can sap your wellbeing and deplete your strength and resilience. Having to cope with continual or frequently recurring back pain whilst dealing with the demands and difficulties of everyday life can feel overwhelming. Back pain – indeed, pain in any region of the body – demands our attention: this is what makes it such an effective signal. Pain usually acts as a protector: it makes us behave, move, and think differently to help the healing process. It can be so effective that it suspends thinking, feeling, or the ability to focus on anything else. And when it persists it can take over our lives.
The good news is that research over the last few decades has produced a new way of viewing and treating low back pain – and it is having astounding results.
The cost of back pain
Back pain is one of the most common reasons for consulting a doctor, taking time off work or using medication. Back pain costs the European economies £12 billion per annum. It is the leading cause of long-term disability in the UK and is linked to other health complaints such as low mood, diabetes and heart disease. In terms of the global burden of disease, back pain was the most common cause of disability between 1990 and 2013. In short, it poses a huge burden on the individual, the health service and society as a whole and the economic costs to healthcare systems, industry and social-welfare support systems are phenomenal.
Until recently persistent back pain was poorly understood. For many years the prevailing assumption was that all persistent back pain must be the result of structural abnormalities of the spine or joints. As in all traditional types of medical training, we were taught to look for a variety of structural abnormalities of the spine, most commonly arthritic and disc disorders, or for a vague group of conditions attributed to poor posture, under-exercise, over-exertion, worn-out tendons, and the like. Sometimes treatments that focused on these structural abnormalities worked, but far too frequently patients returned to the treatment room, frustrated with a further episode of pain, or unable to get rid of persistent back pain. There have been many different theories about which spinal structures are responsible for the pain, but none produced consistent results for people with persisting pain.
Over the past few decades a plausible biological and scientific model has emerged for working with people who suffer from persistent back pain and it is termed the ‘biopsychosocial model’. The biopsychosocial model allows us to understand a person’s experience of their pain in the context of their life, culture, hopes and aspirations, past experiences, thoughts, feelings and relationships, influenced by information gained both consciously and subconsciously from family, friends, media, and healthcare professionals. By exploring these social and psychological factors, we are able to identify aspects of patients’ back pain experience that may be holding up their recovery.
At the same time, our knowledge of pain biology has improved immensely, through some detailed research done around the world by fantastic forward-thinking research teams. This has provided a new framework for helping us to understand better what happens biologically when pain in any part of the body persists, and the role that psychological and social factors play in determining how much pain we feel, how much disability we experience, and, most importantly, what can be done about it. This has helped researchers and clinicians establish new biopsychosocial approaches to treatment, which have shown promising results – results we have seen time and again at our own programme at the Royal Orthopaedic Hospital in Birmingham.
The way we examined and treated patients 20 years ago was a product of what we were taught at university and on postgraduate courses. Since then, we have dismissed much of it, as others’ research combined with our own knowledge and experience has completely changed the way we view low back pain. Many brilliant clinicians and researchers were involved over the years in shaping a new approach, in which patients are encouraged to unlock their own ‘pathways to recovery’. This idea was hugely influential on our own practice. It just seemed to make sense, and as we began to use it we realised that it worked.
Six years ago we were given the opportunity to set up a group-based treatment service at the Royal Orthopaedic Hospital in Birmingham, which would combine physical and psychological treatment principles to help people with persistent musculoskeletal pain, mostly back pain, return to the lives they had before. At the time, NHS guidelines recommended that such programmes should be a hundred hours long. Working in a climate of limited resources, we decided to explore whether a programme that followed the same principles but was much shorter could produce useful outcomes. We managed to persuade our local service commissioners that this service was worthy of the investment, and then set about structuring the service around a 12-hour, group-based treatment, which combined all the latest research on what works for people with persistent back pain. We managed to get funding so that both of us could be involved in the programme and, in time, we also gained funding for the services of a pain counsellor.
Using the structure of existing longer programmes, we established a service that addressed both the physical and psychological aspects of persisting back pain, and the social influences that influence the course of back pain: in other words, the biopsychosocial approach. We offered exercise and relaxation sessions, as well as helping patients to learn about and understand their back pain so that it no longer dominated their lives and their ability to function well. We looked at better ways to help them manage those difficult days and get the best out of medication. We both have experience in occupational health so were able, when needed, to guide people who were having difficulties in their chosen employment, or when aspects of their work were impacting on their health.
It is one thing making improvements in health and function at an appointment with a healthcare professional, but quite another to maintain that progress over time. We placed a lot of emphasis on changes that a person can make within their own environment and ways they can maintain momentum. Underpinning all of this we used a coaching-guiding method in which the person with the problem is viewed as having the resources, usually hidden, to get themselves better.
Pretty soon we recognised that for many people this approach was really working. We were seeing much better outcomes than we could ever have achieved with other treatment methods, such as physical manipulation or injection treatments, or just giving people sets of exercises to do. Using a team-based approach seemed to help them get back to activities they had previously enjoyed; their moods were lifting, they felt less anxious about using their backs for normal daily activities and they frequently reported that they were taking much less, or no medication and feeling better for doing so. Rather than simply being shown how to cope with back pain, people were telling us that they felt liberated from their back pain; that they felt much more in control of important areas of their lives and were in effect in the driving seat again. Moreover, they felt more confident dealing with the turbulent and difficult times encountered on life’s journey, rather than these events ‘flooring’ them.
We think it is important for everyone to have an understanding of the principles we use on our programmes, and those used on other similar programmes, which can lead to a path of recovery. We are grateful that the publishers, Random House, have given us the opportunity to promote the benefits of this approach to a wider audience.
Gavin’s journey
Gavin Newman had spent years building up a career as a singer in pubs and clubs around the West Midlands. He loved singing and was overjoyed when he managed to make it his full-time job. He had a diary full of bookings and was finally enjoying the buzz of earning good money, doing something he had a real passion for. He specialised in singing the Rat Pack songs, such as ‘Everybody Loves Somebody’ by Dean Martin or ‘New York, New York’ by Frank Sinatra, and his routine was full of great material that had his audiences in raptures. He was living the dream and revelling in a world he had longed to be part of for many years. Life was good.
Then, one evening whilst singing on-stage, Gavin noticed a twinge in his back; nothing significant initially but as his set came towards the end, his back pain was increasing. He managed to get off stage but noticed the pain was continuing to worsen. Like most people who experience back pain, he thought it would be better by the morning, so he took himself to bed. The following morning, he woke early. He tried to move but felt an excruciating pain in his back; he felt locked, stuck, unsure what to do. Every time he tried to move he felt an overwhelming pain in his back. He couldn’t even raise himself out of bed.
Pretty quickly Gavin started to feel alarmed. He had several more gigs booked over the next few days. ‘How am I going to manage? I can’t even move,’ he worried. Somehow he managed to get himself out of bed but the pain continued unabated. This was a new experience for Gavin. He had never felt like this before and was sure there must be something seriously wrong. He cancelled the next couple of gigs, hoping to be fit after that but worried deep down that it might take much longer to recover.
Gavin went to see a doctor and was given some advice: ‘Try to stay active and take these tablets. Don’t worry; you will be fine in a few weeks. You will be back singing in no time.’ But this didn’t sit well with Gavin. He was sure there was something seriously wrong with his back, as it was so painful. He was anxious that his singing career, which he cherished so dearly, was in jeopardy; he was worried that he might do more damage to his back if he became more active. Within a few days Gavin started to feel depressed. Each time he went back to the doctor he was given the same message: ‘Stay active, and you will be fine soon.’ The doctor gave him more tablets, different tablets, some of which were stronger and some of which had unpleasant side-effects. Gavin kept following his doctor’s advice but felt he was getting nowhere. He had to cancel the rest of his forthcoming gigs, and this started to hit him financially, adding to his worries. He was spiralling into a cycle of low mood, raised anxiety, distress and hopelessness at his predicament. He felt guilty that he was letting down everyone around him but couldn’t see a way out.
Since he was failing to recover, his doctor decided to request an MRI scan of Gavin’s back. Gavin had to wait several weeks to have this scan, in which time nothing changed. He was still struggling with normal daily activities, such as bending to put his socks on in the morning, walking to his local shop; even standing at the sink doing the washing-up was difficult. Refreshing sleep was non-existent so he was given more tablets to help with sleeping. By the time he had his scan, Gavin felt, in his words ‘doped up to the eyeballs’.
He sat down with another doctor to hear his scan results and was told his discs were degenerating and bulging, and he might need surgery. Gavin felt devastated. ‘How can I go from having a full-time singing career, with a diary full of bookings, some decent money coming in, to this?’ he fretted. He started to worry about his long-term future. He wasn’t keen on the idea of surgery, but he knew he wasn’t getting any better. He was starting to feel lethargic and was losing his motivation. His dreams of a full-time singing career were in tatters. His doctor told him he couldn’t give him any more tablets, as he was on the maximum dose of everything. Gavin felt desperate.
Something had to change.
Gavin was then referred to a doctor at a local hospital who worked in a treatment service that took a different view of Gavin’s back pain. Up to this point, no one had explored the psychological effect Gavin’s back pain was having on him, or the biology of what was happening in his body as this downward spiral had taken hold. No one had considered the social consequences of Gavin’s back pain – the fact that he’d had to give up his singing career and the pleasure it gave him, and that he was suffering financially.
Gavin noticed this new doctor seemed different to the others he had seen. Although sceptical initially, he was reassured to be told that he could get better without surgery. This doctor asked different questions: he was interested in the experience Gavin was going through, the low mood, the anxiety, the uncertainty about the future, the impact the back pain was having on his ability to earn a wage. After gathering all this new information, the doctor examined Gavin’s MRI scan then reassured him that it was safe to start moving, initially at simple levels, and that he wouldn’t damage himself. This news was a revelation to Gavin. No one had told him he would not harm his back if he got moving. He had been convinced there was long-term damage that he would never recover from. His lack of progress, despite treatments he assumed would help, had reinforced the message that there must be serious damage.
The whole consultation with the new doctor was different. Gavin felt understood. His perception of what was wrong and how the future might look began to shift. He was also helped at this stage to understand that all the drugs he had been prescribed were, in fact, making him feel much worse and had become part of the problem. This, he could see for the first time, was within his ability to influence; this was something he might be able to take control of.
But Gavin remained sceptical that he could recover. ‘Why should this work if nothing else has worked?’ he asked. He had to test it out for himself. The doctor asked him to see a physiotherapist and to join a rehabilitation programme that would explore all the different factors that might be causing Gavin’s back pain to persist. Sensing this was going to be different, Gavin went along on the first day. Lingering doubts persisted, though: ‘How can they know what I’m feeling inside my body?’ he thought. The first session was in a classroom, with a group of other people in a similar predicament. Gavin sat there, dismissive of the information he was being given. ‘How can this possibly help me?’ he wondered. He was then taken into a gymnasium and found himself lying on the floor, on an exercise mat, staring at the ceiling, as he was introduced to a relaxation exercise. ‘What the heck am I doing here?’ he questioned.
More challenging for Gavin was what came next. He was instructed to do some exercises: starting to stretch his spine, to bend and then to walk on a treadmill. All these activities filled him with dread. He felt anxious just seeing other people trying them. He could feel his heart beating faster, his palms were sweaty and he was agitated. He knew it would make him worse. But he gave it a go. He got on the treadmill and started walking. Much to his surprise he noticed that he didn’t feel any worse. He managed six minutes. He then tried some other exercises and stretches, and although it hurt initially (which he was told to expect) he found he could do them without feeling worse. This was liberating for Gavin. For the first time in six months he got a sense he was starting to recover. His scepticism started to give way to optimism. This different approach was starting to reap benefits.
He learned that his ongoing pain wasn’t due to his damaged discs but was linked to the fact that he had been avoiding activities he thought could damage him further, and had become fearful of moving his back too much. This, and several other factors, were adversely affecting his nervous system, which had become too sensitive, winding up his pain, and his body had gradually become deconditioned. This made sense to Gavin, particularly when it was mentioned that low mood, anxiety, fear, lack of sleep and worry could have a direct impact on how much pain he was feeling. None of these psychological factors, which had been a key part of Gavin’s pain experience, had been addressed by any of the other health professionals he had seen, but they were one of the main reasons why his pain had persisted. He learned that if he started to build his activity in a step-by-step manner his function would improve, and he started to feel the benefits of relaxation exercises in helping to wind down his oversensitive nervous system.
As part of his recovery Gavin was encouraged to set some goals to work towards. Most of all he wanted to get off his tablets. With the support of his new doctor, he was encouraged to taper them off gradually over a period of a few weeks. As Gavin did this he noticed that the ‘fogginess’ he had experienced over the past few months was starting to lift. He started to be able to think more clearly and noticed that his sleep patterns improved.
The real Gavin was starting to emerge. He was taught what to do if he had another attack of back pain in the future, and every day he practised some breathing exercises he had been given. Although he was still feeling some back pain, within a few weeks Gavin had seen a dramatic improvement. He was exercising regularly, free from medication, and liberated from much of the anxiety, fear and caution that he had developed. Gavin felt his recovery was well on its way. He started looking forward to rebuilding his life.
FOR MANY YEARS now we have been using the biopsychosocial model to work with people with persistent back pain and we have found that most report a significant improvement in function. They are able to return to their usual hobbies, social activities and responsibilities, caring for or nurturing others, or to their paid employment. They regularly tell us they have ‘got a life again’ and that family members have noticed positive changes in their health and wellbeing. Although they might still experience some back symptoms, these usually trouble them much less, and their function and quality of life is significantly enhanced.
In this book we will help you understand how you can apply a biopsychosocial model to help you unlock your pathway to recovery. Whilst it may take some time and perseverance, we now know that it gives you the best chance to restore function, reduce pain and improve your quality of life. So if you feel ready, let’s get going.
The biopsychosocial approach to back pain acknowledges that biological, psychological and social factors all play a role in your experience of back pain. You never get one without the others; they always link together. People with back pain are much more likely to benefit from our treatment if we consider all three of these factors together, as in the story of Gavin earlier. Until fairly recently back pain treatment did not focus on such a broad view but it is now widely accepted that there is an association between psychological, biological and social factors whenever pain is experienced.
From a biological perspective we know that many changes occur in our bodies when we experience back pain: these involve our central nervous system (that is, the brain, spinal cord and the autonomic part of the nervous system – the part that controls internal functions such as heart rate, digestion and breathing); our endocrine system (governing the release of hormones); our immune system (which protects against disease); and our musculoskeletal system (muscles, tendons, bones and joints). These biological changes become more pronounced as back pain persists and play an important role in maintaining back pain and poor function long after we had expected to recover. We still don’t fully understand all the myriad biological changes that occur when we experience back pain but researchers keep revealing new and exciting theories relating to the way these changes link to the pain experience. Learning about these can help you to recover.
From a psychological perspective, we know that when people experience an episode of back pain, there are a range of different responses. Some people become fearful of moving, and worry they might cause more damage to their back. Some avoid activity because they worry they may get a further disabling flare-up of back pain if they push themselves too much. These are normal and logical psychological responses to an episode of back pain, but if they persist unchecked they will contribute to ongoing back pain and poor function. Some people become overwhelmed with negative thoughts relating to their bad back and develop low mood or anxiety, just as Gavin did. They then get stuck in a vicious cycle of fear/avoidance/ negativity which they struggle to recover from. It can be very difficult to break free of this cycle on your own but having an understanding of it will help.
From a social perspective, we know that the circumstances in which you live and work can influence your recovery. If people around you, including friends, family, work colleagues, health professionals or bosses, incorrectly view your back pain as a problem that means you need protecting or as something that could end your career, it will have a significant negative impact on your ability to recover. You might be influenced by stories in the media or online about back pain, but be aware that there is a lot of misinformation out there. These stories could be wrong, and following their advice could have the effect of prolonging your back pain and poor function rather than helping you to recover. Or you may be in a medical system that has long waiting lists, which means several months pass before you get the right advice about your back pain. By this point, many biological and psychological changes could have taken hold and you may find yourself in a cycle of persisting pain and poor function. Understanding how your social life links to your back pain will help you on the path to recovery.
To help yourself restore function and quality of life when back pain persists, it is helpful to understand how the biological, psychological and social systems all combine to maintain your pain problem. To start this process, let’s explore the truth about persistent back pain.
In our experience of working with persistent back pain, we come across many different and potentially conflicting opinions and nuggets of information people have been told about their back pain. They frequently attend our clinics with stories of what clinicians, friends, work colleagues and family members think is wrong with them. This advice has naturally influenced what they think and the way they react to their back pain but, while it was undoubtedly well-intentioned, it is often plain wrong.
It is important to understand the latest scientific evidence.
As you read through the list below, take time to reflect on any differences between what you read here and what you currently believe and understand about your problem. It might be these differences are holding up your recovery.
In the majority of patients back pain is very difficult to diagnose
Despite numerous studies, it has become evident that diagnosing back pain is impossible in about 85% of patients. A very small percentage of people with persistent low back pain – estimates suggest less than 1% – have ongoing pain due to disease of the spine.
There are a number of different diseases affecting the spinal structures that might require medical treatment. These include the inflammatory diseases, some of which have complex medical names that sound scary – including rheumatoid arthritis, ankylosing spondylitis, or infections such as tuberculosis – but their symptoms can be very similar to other more benign conditions. Cancer can affect the spine and untreated will lead to rapid deterioration of health. Some people may have curvatures of their spine sufficiently advanced to affect the functioning of their internal organs, but it is worth mentioning that small curvatures of the spine are remarkably common and harmless although they seem to get the blame for a lot of back pain.
Remember that the vast majority of people with back pain have no