ISSUE 4 n 2015

Cycle framesThe right posture

The ATLAS trialHope for neck pain

Uphill struggleManaging pain

www.backcare.org.uk

FREE TO MEMBERS

Quarterly magazine of BackCare, the UK’s National Back Pain Association

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2 TALKBACK NEWS

TALKBACK l ISSUE 4 2015

BackCare Christmas Carol Concert14 DECEMBER

Join us at the Queen’s Chapel of the Savoy, 6:30pm, for a rich tapestry of choral masterpieces brought to you by the Tredici Choir, led by Richard Thomas. Tickets £18; refreshments available. Box office: www.brandenburg.org.uk/christmas. Proceeds go to the charity.

ACTIVE Working Summit 201628 JANUARY

“The Sedentary Office – Building the Evidence to Justify Change” at More London Place, London SE1 2AF. Second annual conference exploring the health risks of prolonged sitting. Visit www.getbritainstanding.org to view the programme and book your place.

18th International Acupuncture Research Symposium 201619 MARCH

“All in the mind?” at King’s College London (Stand campus). Research and education seminars supported by the British Acupuncture Council, Acupuncture Association of Chartered Physiotherapists, Register of Chinese Herbal Medicine and Association of Traditional Chinese Medicine. Visit www.arrcsymposium.org.uk for more information.

BritSpine 20166 – 8 APRIL

Biennial Scientific Congress of the British Association of Spine Surgeons, the British Scoliosis Society and the Society for Back Pain Research. Nottingham Conference Centre. More information at www.britspine.com

BackCare Events Calendar 2015-2016

Councils invest in The Carer’s Guide

www.backcare.org/carers

Standing for President 4

Mountain high 12-13

Back pain myth 18-19

Neck pain hope 20-22

On your bike! 14-15

Road to a better life 16-17

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BackCare16 Elmtree Road, Teddington,Middlesex TW11 8STTel: +44 (0)20 8977 5474Fax: +44 (0)20 8943 5318Helpline: +44 (0)845 130 2704Email: info@backcare.org.ukWebsite: www.BackCare.org.ukTwitter: @TherealBackCareRegistered as the National Back Pain Association charity number 256751.TalkBack is designed by Pages Creative www.pagescreative.co.uk and printed by Severn, Gloucester.

We welcome articles from readers, but reserve the right to edit submissions.

Paid advertisements do not necessarily reflect the views of BackCare. Products and services advertised in TalkBack may not be recommended by BackCare. Please make your own judgement about whether a product or service can help you. Where appropriate, consult your doctor. Any complaints about advertisements should be sent to the Head of Information and Research.

All information in the magazine was believed to be correct at the time of going to press. BackCare cannot be responsible for errors or omissions. No part of this printed publication may be reproduced, stored in a retrieval system or transmitted in any form or by any means without permission of the copyright holder, BackCare. ©BackCare

Dr Adam Al-KashiHead of Research

& Editor of TalkBack

Hello friends,Welcome to our final TalkBack of 2015. I hope

you’ve done all your festive shopping and got everything sorted out. The dark mornings and short days are not everyone’s cup of tea, but 22 December is the shortest day this year, which in a sense marks the beginning of the long run-up to summer – although you’ll have to wait until 6 January before the sun begins to rise earlier again!

TalkBack goes out in print to all our members, but perhaps you’ve picked up this copy at an event or are reading this online. However we’ve crossed paths today, we’ve got a great issue for you. BackCare publishes TalkBack quarterly and now also sends out a free monthly email newsletter which you can sign up for on our website at www.backcare.org.uk/join.

Since we last convened, we’ve had a very successful BackCare Awareness Week. The campaign focused on back pain in children, with a radio day reaching seven million listeners with the message that prevention must begin in schools – a quarter of UK schoolchildren suffer daily back pain. You can read all about it on pages 5, 8, and 10.

We continue our series of practical advice from Yoga for Healthy Lower Backs and the Society for the Teachers of the Alexander Technique on pages 6 and 7 – two of the best-evidenced approaches for reducing the frequency and severity of back pain. In fact, we also have a full report from the authors of the ATLAS trial which measured the effect of the Alexander Technique and acupuncture on people suffering long-term neck pain (pages 20-22).

We’ve got two inspirational pieces from long-term pain sufferers for you. Firstly, Gillian Fowler returns from Morocco’s Atlas Mountains with her personal account of living in the spirit of adventure (pages 12-13). Then, we have keen cyclist Daphne Kaufhold, who tells her story of

injury and chronic pain, and how she was driven to launch the “1in7” campaign (pages 16-17).

Hats off to Mary Burstow who, rather astonishingly, has single-handedly tripled our marathon team applications – we now have a full team of 45 runners in training. Mary gives us her usual lowdown of what’s trending on social media (page 8). We also have Nick Sinfield, who continues his run of myth busting, assumption challenging and habit changing on page 9.

Finally, after four great years at BackCare, I will be moving on in the New Year, so this will be my last issue of TalkBack. I hope you’ve enjoyed reading TalkBack as much as I’ve enjoyed my involvement in its production. That just leaves me to thank all the great people I’ve met along the way as Head of Research and Editor of TalkBack – colleagues, collaborators, contributors and, of course, you, the readers.

Wishing you a Merry Christmas and a Happy New Year

Welcome

TALKBACK WELCOME

Contents

4 TALKBACK NEWS

TALKBACK l ISSUE 4 2015

Even the US President stands at his desk

Ironman Jason completes a week of triathlons

This year, BackCare became the first UK charity to go 100% sit-stand, enabling all staff to alternate between sitting and standing at the desk through kind donations from Varidesk and Orangebox.

Many employers including Google, Twitter and Facebook are doing the same in light of evidence

linking prolonged sitting with obesity, diabetes, heart disease and depression.

Now, following a recent public solicitation, it appears that President Obama is opting to sit-stand, with his Executive Office set to invest $700,000 in sit-stand desks for the White House.

In 2010, after recovering from back pain surgery, Jason Roberts raised money for BackCare by completing a gruelling Ironman triathlon – that’s a 2.4-mile swim, 112-mile bicycle ride and a 26.2-mile run, back-to-back within 17 hours!

Well, he was clearly bitten by the bug, because, in August, Jason (pictured left) returned to complete an incredible “7-day-7-irons” – yes, that’s right, an Ironman triathlon every day for a whole week.

Proceeds from this feat go to supporting children suffering poverty and abuse. Well done Jason!

Award winnerCongratulations to health economist Dr David Whitehurst at Simon Fraser University in Canada and colleagues at Keele and Cambridge Universities who won this year’s BackCare/SBPR Research award.

Their work, entitled “Implementing stratified primary care for low back pain: cost utility analysis alongside a prospective, population based, sequential comparison study”, demonstrated that treating back pain patients according to their risk of disability (as assessed by psychosocial factors) can save six days of sickness absence from work and around £700 in treatment costs per medium or high-risk patient.

Marathon places snapped upWell done to Mary Burstow (a.k.a our communications team) who has single-handedly tripled marathon team applications since last year.

We were flooded with interest and have filled all of our 45 Gold Bond Places for the 2016 Virgin London Marathon.

Many thanks to all who applied and congratulations to those who secured a place and are now in training!

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Pupils weighed down by heavy school bags

3,000 new practitionersjoin list

Summit on MSDs backs self-manage approachIn October, BackCare attended a parliamentary summit on musculoskeletal disorders (MSDs) as part of our involvement in the Fit for Work UK coalition. The discussions focused on how to improve early diagnosis and management of MSDs to ensure people of working age living with an MSD are supported to stay in work.

Perhaps most significantly, it was agreed that patients should be empowered to self-manage

their condition and prevent it worsening. This represents an important shift up from

traditional healthcare – where the patients simply consent and comply with passive treatments – towards a more proactive approach where patients are very much in the driving seat, supported to make long-term changes to the lifestyle factors that govern the progression of long-term conditions.

We’re pleased to announce that 3,000 acupuncturists have now joined BackCare’s online practitioner search following new partnership with the British Acupuncture Council.

The partnership is part of a new approach which aims to create the first complete multi-disciplinary listing of back pain professionals in the UK. We are already in talks with the other major professional bodies that register healthcare professionals who treat back pain and will keep you posted.

This year’s BackCare Awareness Week campaign, which focused on back pain in children, was a huge success. We surveyed 900 secondary school pupils, revealing that 1 in 4 experience daily back pain.

We also found that half felt their schoolbag was tiring or too heavy for them, and back pain was 10 times more common among this group. The overall message was that back pain prevention needs to begin at school and we reached close to 7 million listeners through our radio day.

We also had an array of local activities during the week through our branches and professional members. Lyndee Oscar of the new Essex branch (see page 10), who is particularly passionate about back pain in children and offers workshops to students in schools in north Essex, says in her experience youngsters often don’t talk about their back pain but accept it as a part of life.

Lyndee Oscar teaching back care to pupils at Colchester Academy

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TALKBACK SELF HELP

What to do if you get a sign of a painful back episode

How to perform the pose:Lie on your back and, on an exhalation, bring your knees in towards your chest. Hold the knees with your arms by interlocking your fingers past your shins. Have a book/block under your head, if necessary, to keep your chin at the same height as your forehead (never above that height). Remain still and breathe steadily.

Jelly wobble Keeping your body relaxed, gently jiggle your legs in and out (an inch or two) in a minimal and quick way so that your whole body relaxes and wobbles. Up to 60 seconds.Observations:l Observe how the skin, flesh, muscles and bones seem to move like separate layers as you relax and jiggle more.l Notice how the wobble goes all the way up to your head.

Spinal rockSlowly and gently rock from side to side, observing your back’s contact with the floor and allowing your back to feel massaged by the floor. Up to 60 seconds. Then hold still for up to 60 seconds.Observations:l Observe the gravitational effects as different parts are leaned into.l Observe how some parts of the back are more tender or bony than others, but how the more often this is done, the more comfort and evenness is felt.l If the bones of the middle of the back feel they are getting bruised, take the knees a little

further away (extra padding can be used under the body).l If the back of the pelvis feels too tender, bring the knees a little closer in.l Should there be restriction or tenderness at the front of the groin when bringing the knees in, ease the knees away and relax the muscles and tendons at the front hips and bring the knees in slowly on the exhalation with relaxation.Benefits:l Massages the back and mobilises the joints.l Stimulates acupressure points for pain relief.l Strengthens the abdominal and side waist muscles.l Gentle stretching of the facet joint capsules and lower back muscles.l Reduces any inflammatory conditions (joint capsules, muscles, etc) and wind and constipation.l The first “forward bend” action after a herniated disc, encouraging healthy healing of the disc wall.l Lessens lumbar lordosis (inward curve/sway back).l Brings the body back to compact symmetry.

Here is one pose that may or may not suit you. The feeling here should be “Mmmmm, lovely” – do not do anything that does not feel 100% comfortable. It is not what you do, but the way that you do it that is important. You are responsible for your own actions. This yoga should be gentle, easy, brief, comfortable and pain-free.

Some yoga poses can act as natural pain relievers. You should choose just one. They are best performed after you have learned them under the guidance of a knowledgeable teacher.

They constitute positions where the body and mind can feel completely passive and at ease – you should not experience any tension, worry or sensation of stretch.

Your favourite effective pose this month may not be the same pose next month or next year. They act preventatively, when your back feels “twinges” or “niggles”. Do not underestimate the power of the exhalation

to relieve pain and quieten the mind.1) Do at least 15 minutes of relaxation on the floor (choose a suitable and comfortable lying position) from the Yoga for Healthy Lower Backs Relaxations CD.2) Adopt one of the seven “relief poses” (one pictured above) and concentrate on

breathing steadily, focusing on the relaxing exhalations. Exhale to enter and exit pose: easy, comfortable and pain-free.3) Be especially aware of your posture, movements and sitting position. Aim to relieve tension and don’t challenge your back for a few days.4) Don’t despair, but learn from the build-up, recovery and rehabilitation.5) Keep positive. Know that you can help yourself.6) After one or two days of doing the above, return gently to your usual yoga session, provided it is pain-free.

2 Pain relief

Yoga for healthy lower backs

Double leg lock – supta pavanamuktasana

This article is mainly taken from a Lotus Publishing book, Yoga for Healthy Lower Backs, written by Alison Trewhela & Anna Semlyen. The book was written as a manual used in The University of York Department of Health Sciences randomised controlled trial funded by Arthritis Research UK to accompany a successful 12-week specialised, gentle yoga

programme. It was shown to be cost-effective for the NHS and the workplace (70% reduction in

workplace absenteeism). The Yoga for Healthy Lower Backs Institute trains experienced yoga teachers in individualised back care and how to deliver this best practice, evidence-based course that teaches long-term self-management

skills. More information: yogaforbacks.co.uk

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TALKBACK SELF HELP

Two easy routines to help you regain your inner balanceFinding your feetPart of learning the Alexander Technique is finding out more about what your skeletal system is like. This is useful as our ideas of how we are made up can make a big difference to how we move and how we approach tasks and activities. Our feet are a good example of this. Have a go at this exercise which could help you walk more comfortably, improve your balance and help you to feel grounded.1 Walk a few steps (preferably without shoes) and notice what your feet feel like on the floor and how they move.2 Draw a very simple sketch of your lower legs and feet – what would you draw? It might be like one of the illustrations below or it could be something quite different.

(a) (b)

Most people think of their legs and feet as making an L shape (a) but in fact our legs and feet are more like an upside down Y (b). We have a section of foot behind our ankle joint as well as in front. The importance of this is that it is a more stable shape so it gives us better balance. The Y shape also shows that we have an arch to our foot, which gives us a bit of springiness.3 Walk a few steps again with the thought that your foot is like an upside down Y. Notice what your feet feel like on the floor and how they move. Has anything changed?

Notice your feet as you walk over the next few days, have the upside down Y in mind and see what happens.

Learning the Alexander Technique has been shown by randomised controlled clinical trial to have long-term benefits for people with chronic and recurrent back pain. Researcher and teacher of the Alexander Technique, Lesley Glover shows that while learning it involves one-to-one lessons, there are many tips we can take away and explore by ourselves.

Approach to improve health and wellbeingThe Alexander Technique is a self-management approach which offers people of any age or ability a way to improve their health and wellbeing. It can be applied in all situations in everyday life and can lead to better balance, co-ordination and freedom of movement. It can increase confidence, self-awareness and provide greater control over your actions. It is widely used to reduce pain as well as to improve performance in sport, music and drama, public speaking and interview technique. Find out more at www.stat.org.uk

Lying down as a pick-me-upLying down may not seem the most active or productive thing to do, but even a few minutes a day can make a big difference to how you feel if you follow these guidelines.

This kind of lying down can be thought of as active rest. It allows the muscles that are used to support you in an upright position to release and lengthen. It helps to align your head, neck and spine and gives the spinal discs an opportunity to reabsorb fluid and increase their “cushioniness”.

The reduction in muscle tension can aid digestion and breathing. Regular practice of lying down can lead to an increase in energy levels, alleviate pain and improve self awareness.

Start by lying on the floor in a warm place. Place your head on a book or books so that your head, neck and back are all in alignment. If the books feel too hard, put a thin cloth over them. Your knees should be bent with your feet about hip width apart. Your hands can either be placed by your sides on the floor or on your abdomen. If

you find that your shoulders are raised off the floor, you could put a pillow under each one. The idea is not to lift your shoulders but to allow them to release into something. Have your eyes open and let them rest as they take in the colours and objects around. Allow yourself to be aware of the sounds around you.

The first thing is to “arrive” on the floor. Pause for a moment and allow yourself to take in where you are and to acknowledge that, for the next few minutes, you can stay here and just be present.

Notice the floor underneath you, the places where your body touches the floor. Invite the muscles of your back to release into the support of the floor. You do not need to do anything, just notice and invite.

If your mind wanders, gently bring your attention back to you and to your connection with the floor, then notice something in the room. Start by doing this for five minutes once or twice a day.

When you have finished, roll to the side and get up slowly. When you are standing, pause for a moment, notice your connection through your feet to floor, notice the whole of your back and recall the connection it had to the floor.

Give it a go and see what changes for you.Lesley Glover

www.lesley-glover.co.uk

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TALKBACK SOCIAL MEDIA

Mary Burstow’s social media round up

We are @TherealBackCare

Hannah Louise Epps @farnhampilates Oct 9Final day of #backcareawarenessweek and here is our final exercise. Have you tried them? #backcare https://youtu.be/NOOIW8Z18Ns

Kidsbacks4thefuture @Kidsbackcare Oct 7I’m with Back Wise Savvy students today! @TherealBackCare #BackCareAwarenessWeek-prevention in schools! #fit4life

Richmond Stace @painphysioC - compassionA - authenticR - rapportE - empathy #care the heart of working with people suffering #PainCoach

Tom Sullivan @TomSullivant Oct 6Physio Angela Clarke @BelfastTrust gives advice to St. Ita’s pupils to mark #backcareawarenessweek @JohnODowdSF

Andrew Murray @docandrewmurray Dec 1If you can’t make the time for exercise, you will have to make time for illness (various)

Mary Burstow

Twitter was alive with BackCare Awareness Week this year. It was really good to hear how our members went out into the community to spread the word on good back care and wellbeing.

I loved this You Tube that Farnham Pilates produced.

This recent tweet, from a member, gets to the heart of what working in pain management is all about.

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Happily, we live in exciting and changing times in the treatment of back pain. Leading physiotherapist Dr David Butler says, “it is no longer acceptable that pain be just managed: we must expect that it can be treated and sufferers can alter it themselves through education.”

Thankfully, the latest clinical research points to a shift away from managing or coping with long-term pain to being able to alter and improve pain. The challenge for all healthcare professions is to provide treatment programmes for back pain in line with this latest research.

The effective treatment of long-term back pain must be able to identify the different connecting factors to your pain. This must focus on the overlapping parts to a pain experience; this will be influenced by: l changes to your thoughts and behaviours due to the pain l changes physically or to your sleep due to the painl changes to your work or home life due to the pain.

These connecting factors will provide you with a personal pain experience based on all your past and present back pain understanding.

This is complicated, so let’s

look at an example. Two people go on the same car journey; if you asked them to remember a few memorable highlights of the trip they might well tell you completely different things! The same can be said for someone’s pain experience – two people with the same injury could report different levels of pain and return to everyday activities at different rates.

Unfortunately, back pain can lead to the development of some bad habits. This can include changing how you move or perform certain

activities, or holding your back in a rigid, protected way. This can have a knock-on effect such as muscular changes, tightness and ongoing pain. These secondary physical changes can lead to continuing pain and anxiety.

Overcoming these physical changes should focus on increasing movement and

exercise. This can be helped psychologically by challenging unhelpful and incorrect beliefs about your back pain.

Let’s look at an example: thinking, “My back will never get better” may well lead to a self-fulfilling prophecy! How about changing this to, “I’m taking responsibility for my recovery now”, or, “I need to make some changes but I will get there one step at a time.”

This is an important step to increasing your confidence that movement is medicine.

Here is Joe’s story: “Following many years of back pain, I began to appreciate that my thoughts and beliefs of what was happening and how my body felt were not the absolute truth. Challenging my thoughts allowed me to view my body not as a ‘broken’ machine, but as a confused, overprotective machine. I began to appreciate

that my body’s symptoms often reflected what was happening in my mind, too, and sometimes my symptoms were directly related to my beliefs, thought patterns and emotional state through forms of stress. I began to appreciate that my body was not creating problems or attacking me. It was always trying to do its best to survive even when it got stuck in fearful and non-productive patterns. My back was never the enemy after all.”

This gives us all a reason to be optimistic. So don’t just cope with your back pain…recover!

9TALKBACK SELF HELP

Reasons to be optimisticIn this four-part miniseries, NICK SINFIELD tackles four of the most commonly held back pain myths that delay or even prevent rehabilitation and recovery. Nick is a chartered physiotherapist, BackCare’s Clinical Advisor and Clinical Director for Spring Active.

“Pain management doesn’t work for me” – MYTH!

Part 4:

Unfortunately, back pain can lead to the development of some bad habits. This can include changing how you move or perform certain

activities, or holding your back in a rigid, protected way.

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TALKBACK BRANCHES

CAMBRIDGE • 56 membersContact: Ms Mary GriffithsEmail: blincomary@gmail.com

READING • 24 membersContact: Mr David LairdTelephone: 0118 947 0709Email: davidlaird@talktalk.net

DERBY • 61 membersContact: Mrs Christine SissonsTelephone: 01332 763636Email: chris.sissons@btinternet.com

SALISBURY • 122 membersContact: Mrs Barbara WhiteTelephone: 01722 333925Email: white.alan@btinternet.com

ESSEX • first meeting, 9 OctoberContact: Mrs Lyndee OscarTelephone: 01206 804353Email: lyndee@kidsbacks4thefuture.co.uk

SOUTHAMPTON • 32 membersContact: Mrs Jo Goudge-RileyTelephone: 02380 464170Email: goudgeriley@gmail.com

HARROGATE & DISTRICT • 32 membersContact: Mrs Lin TippeyTelephone: 01423 865946Email: keithandlin2@btinternet.com

SWANSEA (WALES) • 56 membersContact: Ms Gloria MorganTelephone: 01792 208290Email: gloriamorgan@talktalk.net

HULL & EAST RIDING • 90 membersContact: Mrs Beryl KelseyTelephone: 01482 353547Email: kelsey59@kelsey59.karoo.co.uk

WEST LONDON • 15 membersContact: Mrs Teresa SawickaTelephone: 020 8997 4848Email: tere_ss@yahoo.co.uk

LOTHIAN (SCOTLAND) • 66 membersContact: Mrs Jean HoustonTelephone: 0131 441 3611 Email: jean.houston@blueyonder.co.uk

WEST MIDLANDS • 11 membersContact: Mrs Thelma PearsonTelephone: 01902 783537

POOLE & BOURNEMOUTH • 5 membersContact: Mrs Patricia BowmanTelephone: 01202 710308Email: patriciabowman@ntlworld.com

WINCHESTER • 39 membersContact: Ms Gillian RoweTelephone: 023 8025 2626Email: gillianmrowe@hotmail.com

The BackCare branches are a network of local support groups up and down the country. They are run by local members who organise educational, social and fundraising events. You can find your local branch in the listing, right.

If you’d like to start a branch in your area, please contact branches@backcare.org.uk

BACKCARE BRANCHES

Essex branchThe new Essex branch has been going from strength to strength since it was founded earlier in the year by Lyndee Oscar and Ned Wombwell, who are both osteopaths and BackCare Professional Members.

They hosted a stand at Street Wise, a wellbeing event in Colchester in the summer, and were very active during BackCare Awareness Week in October (see page 5),

when they also had their official launch which was attended by the Mayor of Colchester, Theresa Higgins.

Lyndee has been taking the pressure off Head Office by unofficially coaching several other BackCare Professional Members who’ve come forward and shown an interest in setting up a BackCare branch to serve their local community – many thanks Lyndee!

Above: branch lift-off, from left to right, Lyndee Oscar, the Mayor of Colchester Theresa Higgins, and Ned Wombwell cut the cake

Once medical clearance is given, physical activity is usually recommended to help manage low back pain (LBP). Starting gently, moving regularly and progressing activity levels steadily is the way forward.

Inactivity itself is self-perpetuating. Activity can initially be uncomfortable, indeed the more sedentary or unfit you are the longer it takes before physical activity becomes inherently rewarding (ACSM 2010:700). Nevertheless, the rewards and benefits to general health and wellbeing in addition to the management of LBP far outweigh the initial discomfort, so moving regularly and staying motivated is important.

We are responsible for our own self-care and health. The body will respond to, repair and strengthen the structures that we use regularly. The reverse is also true as underused structures weaken. No one can fix this for us. We often require support from healthcare and fitness professionals, but, ultimately, we ourselves have to act to gain a health response.

Exercise principles and progressing activityExercise only works if we do it! Overload and progression govern the body’s response. To overload, we do something more than we have been and the body will adapt and increase capacity, this leads to progression. As our capacity increases we gradually increase what we are doing at a manageable rate, so setting goals is important (Bouchard, Blair & Haskell 2007:304).

The thought of exercise can be daunting initially. To begin with, start moving frequently during the day. Moving joints through their available range of motion assists the synovial fluid and encourages blood flow through the muscles leading to increased comfort in movement. I like to use long, slow breathing with movements on the exhale. This gentle movement can start to relieve tension, releasing stress and overprotective muscles, allowing the body to move more freely.

Begin by trying small range, slow pelvic tilting movements and/or moving the pelvis laterally (side to side) if tilting is initially uncomfortable (these are best carried

out face up on a floor mat with the knees bent). Gradually increase the range and planes of movement, easing the body into daily activity while addressing stress with focused breathing and movement. Using relaxing music can be helpful.

WalkingThe aim should be towards being active to a moderate daily intensity. The Department of Health (2011) guidelines advise that adults should minimise their time spent being sedentary and should aim to be active daily to a moderate intensity of 10 minutes plus increments accumulating to a minimum of 30 minutes’ activity on at least five days a week. As mentioned in the previous article, a level 3 or 4 REP (Register of Exercise Professionals) fitness professional would be able to assist with individual exercises of an appropriate type and level.

The GP doctors that I interviewed for my research investigation recommended walking, and individuals managing LBP agreed they found walking beneficial. The Walking for Health Organisation publication (De More 2013:9) explains that activity causing you to breathe harder and your heart beat faster while you are still able to comfortably carry out a conversation would be classed as moderate.

When walking as a physical activity, it can be helpful to use a pedometer. This

counts steps unobtrusively during a typical day which allows you to record your current activity levels. This can be used to set goals to increase the number of steps progressively.

Individuals who find walking enjoyable may consider trying Nordic Walking. Nordic Walking UK suggests that using the specific pole technique of Nordic Walking adds benefits by the addition of using upper body muscles and that using poles reduces the pressure on knees and joints, with benefits to those with neck, shoulder and back problems (Nordic Walking UK 2015).

With an understanding that movement aids health and function and with confidence that the spine is strong and, to stay healthy, needs to move, then movement can progress through pain-free ranges and be built upon. While initially limiting exacerbating movements, as confidence increases we gradually introduce movements progressing to full range and activity. Physical activity is a progressive, long-term necessity for back health and general wellbeing.

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TALKBACK SELF HELP

Gently does it…

REFERENCES:1 American College of Sports Medicine. (2010) ACSM’s Resource Manual for Guidelines for Exercise

Testing and Prescription, 6th edn. Philadelphia Lippincott Williams & Wilkins2 Bouchard C, Blair S, and Haskell W (2007) Physical Activity and Health. Champaign: Human Kinnetics 3 De More D (2013) Walking for Health; Walking Works.Available from https://www.walkingforhealth.org.

uk/sites/default/files/Walking%20works_LONG_AW_Web.pdf [24 October 2015]4 Department of Health (2011) Fact sheet 4: Adults (19-64 years). Available from https://www.gov.uk/

government/publications/uk-physical-activity-guidelines> [18 September 2015]5 Nordic Walking UK (2015) About Nordic Walking. Available from http://nordicwalking.

co.uk/?page=about_nordic_walking&c=2

Part 2:

Caroline van der Heiden, in her second article, sets out a simple activity that people can do to modulate their

long-term/persistent pain.

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TALKBACK INSPIRATION

BackStrong Adventures specialises in challenges for those with an adventurous spirit and especially welcomes enquiries from those celebrating life who have experienced trauma, injuries, loss, depression, disability, disease and any other life-changing ailment. Visit www.backstrongadventures.com

BackCare writer Gillian Fowler, who is also founder of BackStrong Adventures, tells us about her latest adventure – trekking in Morocco’s Atlas Mountains and climbing Toubkal, North Africa’s highest peak

The sky’s the limit – climbing high to inspire others

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TALKBACK INSPIRATION

n To find out more about this adventure, or other trips, go to www.backstrongadventures.com or email info@backstrongadventures.com

’’

‘‘Without a doubt, I was very excited to undertake this Atlas

Mountains trek, which would see the group trekking across three valleys, over two mountain passes and summit Toubkal. As with all the other BackStrong Adventures trips, I knew I could adapt the delivery so that I could not only enjoy the trek, but thoroughly enjoy the adventure and achieve my dream climbs. But it was time to test the theory out!

I travelled to Marrakech via Frankfurt by myself, so I had to contend with my luggage (soft-sided duffel bag as it was going to be carried by mules) as well as a small rucksack. Due to my spinal injuries, this is always something I dread, because of seating issues and pain triggers, as well as moving luggage! Regardless, after a long wait in Marrakech’s Passport Control, I was met by my Meet & Greet taxi driver and taken to the hotel.

I was looking forward to the evening where a friend, Hannah Melville, would join me, as well as two others, Ruth Henderson and husband Bill Boyd. Our mountain guide, Youssef Elouali Kaissar, gave us an initial overview, including a reality talk of the dangers ahead and never to underestimate the mountains.

There is something incredible about joining adventure groups, especially a small one. A great bond quickly grows between those taking part, a strong team dynamic forms and everyone looks out for each other, encouraging and supporting each other. Without doubt, my Atlas Mountains trek had such a caring group.

Because I was not able to carry weight on my back, chef Abraham was my ‘porter’ in that he carried my day sack with water, clothing etc. We were certainly glad to reach our accommodation each day and get into our sleeping bags, sometimes on a mattress on

a concrete floor, other times the luxury of on an actual bed.

Youssef was full of facts and interesting history, and so not only did we experience a fantastic week of trekking but also a great insight into the country, culture, people and history.

As we were climbing to a height of 4,200m, with varying climbs over the days of 3,100m and 2,400m, we faced the effects of altitude – each of us suffering varying degrees of altitude sickness.

Terrain was variable, from initial vehicle dirt track on the morning of day 1 to the rest of the week being loose stone with large boulders on steep gradient. At times we would walk for hours on a steady, steep incline; posture was key to limiting pain. Thank goodness for walking poles!

We started the final climb in the dark, using head torches as we began our ascent, clambering up rocks, scrambling and keeping a steady, slow pace, with stops once an hour. As the sun rose and we reached the first summit point at 4,000m, the scenery of the Atlas Mountains came into view. It was breathtaking.

Reaching Toubkal’s summit at 4,200m proved to be very emotional, with tears streaming down my face at the realisation of such a great personal achievement. I was lucky to share a truly memorable experience with an incredible group of people, each having their own personal reason to do this adventure.

The sky’s the limit – climbing high to inspire others

I am now in training for my next trip which sees me return to Africa, but this time Tanzania. I will be joined by my surgeon, physio and three others to climb Mt Kilimanjaro, and we are raising awareness of spinal conditions and research. We have set up an online Virgin Giving page to raise funds for BackCare and BackStrong Trust: http://uk.virginmoneygiving.com/team/kili2016

Kilimanjaro in Gillian’s sights

At the summit of Toubkal, from left,

Hannah Melville, Bill Boyd, Ruth Henderson and

Gillian Fowler

View over the Atlas Mountains at 4,000m

Guide Youssef leads the way

14 TALKBACK FEATURE

TALKBACK l ISSUE 4 2015

Cycling is really on a roll, as Green issues come to the fore and

ownership of health is being taken more seriously. In London, for example, which is not the most cycle-friendly city, the number of cyclists in the rush hour is growing exponentially and a critical mass for safety, akin to Amsterdam or Copenhagen, is not far away.

But my interest in the “How To” of pain-free cycling came about during three years of my Alexander Technique training in the early 1980s. At that time, I was living in central London and the Alexander Technique college I was attending was in east London. After cycling from home to the school, and then studying until around 2.30pm, it was off on my bike to be a part-time dental surgeon in north London, and then, around 7pm, a long pedal back home. I was probably averaging around 25 miles cycling a day.

Progressively, my understanding of back pain and cycling issues evolved and clarified.

Interestingly, in Issue 3 (2015) of TalkBack, the Alexander Technique teacher and social anthropologist Dr Sean Carey noted how “a well co-ordinated person with an extended S-shaped spine” is capable of standing pain-free for hours, “their body weight transmitted efficiently through to their feet to the centre of the Earth”.

The issue that affects us all, whether

waiting at a bus stop or queuing at a supermarket or sitting at an office computer or on a bike saddle, is the need to maintain that “extended S-shaped spine”. This is real “core strength”.

Through observation of myself and others, it became clear to me that most of the back problems that Alexander Technique teachers routinely encounter in their teaching rooms were always in plain view on the streets; in particular, the tendency of many (or even most) cyclists to unknowingly or intentionally assume a C-shaped spinal curvature as they pedal along the roads. In short, they have lost that extended S-shaped spine, basically by “collapsing” the lower lumbar curve, while sitting in the saddle... or in front of the computer, for that matter!

Interestingly, even the Tour de France winning Sky Cycling team coaches now recommend that “the rider should cantilever their torso out from their pelvis with no more effort required of the upper body during periods of high intensity than the minimum necessary to steer and control the bike”.

So the big question is: what advice could be given to a cyclist with or without back pain that could be understood without the need for one-to-one instruction from a qualified teacher of the Alexander Technique?

Probably the best place to start is on a static cycle at the gym or in the home. The use of a full-length mirror is recommended so that you can be objective about what is happening rather than relying on sensation or feeling. A few points worthy of consideration are:

First, when sitting in the saddle, your legs need to be fully extended, the knees fully open when the pedal is at its lowest position.

Second, while sitting fully upright on the saddle with that extended S-shaped spine intact, place a forefinger from both hands on your hip joints in the deepest crease point that the fingers can find, when one at a time your knees are lifted upwards. I must stress the importance of performing this action and locating the hip joints

Get on that bike, but make sure you have your posture right

The issue that affects us all… is the need

to maintain that extended S-shaped

spine. This is real core strength

By Barry Collins

15TALKBACK FEATURE

TALKBACK l ISSUE 4 2015

because most of us mistakenly think that the hip joints are much higher than they actually are – around the belt line. This is a major mistake.

Now, with the fingers of both of your hands remaining at the hip joints, allow your torso to cantilever forwards from these finger points, while maintaining length along your S-shaped spine. You can then place the heels of the hands on the tops of the handle bars. You should also be aware that your elbows need to be fully open and your arms straight, so that the weight of your head and torso passes into the handle bars.

In my observational experiments, I came to realise that the reason most people have problems in cycling is that the handle bar stems on most over-the-counter bikes are much too long, the handlebars set too far away, and too low for the average rider.

A better arrangement involves positioning the handlebars (of any shape) closer to the body and more or less level with the height of the saddle. Without changing any bike parts, it is usually possible to move the saddle forward on its rails and to check whether any adjustments are possible in the handlebar stem. Dutch style, “sit up and beg” is probably the best, but seriously un-cool for most of us.

The big issue is whether the cyclist can maintain this upright but cantilevered forward spine while coping with traffic and

pedalling the bike. So, the bike design is only one issue, and the more important one is getting the rider to really think about just what they are doing... back pain of course, is a wonderfully motivating factor! A rule of thumb is that one third each of the cyclist’s weight should be given to the saddle, handlebars and pedals. The rider must neither grab-and-pull on the handlebars, nor heave-ho on the pedals, as both actions create spinal flexion and can initiate lower back pain.

The pedals need to be spun easily and this is best achieved by firstly adopting a low enough gear of the many to choose from, and then think of NOT pushing the pedal down, but COUNTER-INTUITIVELY, lifting the knee of the opposite leg. This may sound daft, but in reality the pedals will be suitably energised, not by the heavy-duty quadriceps muscles but rather by the muscles of the hip flexors (the strongest muscles of the torso). The quadriceps will be involved, but only indirectly. If the bike has toe straps (as per static gym machines) or cleats, then lifting the knee will be easier to accomplish. With an upward movement of the knee, the need to grab and pull the handlebars, and then create a C-shaped back, is minimised.

In essence, in biomechanically efficient cycling we are practising extension – in particular, keeping that S-shaped fully

extended spine allows free movement of the hips, knees and ankles, and allows the rib cage to have maximum freedom to supply oxygen to the muscles.

But I will give the last word to the coach of the Sky Olympic Cycling team, who sums up the challenge of riding any bike efficiently: “...if you want to breathe to fullest capacity, then these (spinal flexor) muscles need to be able to relax to allow full breathing. This isn’t possible if they carry tension, either because they are being used to bear weight or to resist pedalling forces. Equally, many riders have poor ability to extend their thoracic spines and result in sitting on their bikes with a pronounced C-curve in their spine as viewed from the side. If you function like this, you are reducing your effective lung capacity as limited ability to extend the spine means a shorter effective torso length, which in turn equals lack of room for the lungs to expand.”

Get on that bike, but make sure you have your posture right

Dutch style, “sit up and beg”, is

probably the best, but seriously un-cool

for most of us

Barry Collins cycling in the Spanish Pyrenees

16

TALKBACK l ISSUE 4 2015

TALKBACK INSPIRATION

17

TALKBACK l ISSUE 4 2015

TALKBACK INSPIRATION

I studied at Birkbeck University, London, obtaining a BSc and MSc in

Psychology, and was heading for a career in organisational psychology when I was involved in a car accident in April 2010. It left me with severe whiplash to the neck, back and shoulder. I hoped the pain would soon ease.

Weeks of agony turned into months, and months into years. My health deteriorated and the pain spread to other parts of my body, despite my trying everything the doctors recommended.

As a result, I cannot sit down for prolonged periods and I am in constant, chronic pain. Imagine the worst pain you have ever had — now imagine that it is never going to go away.

As time passed, it became clear that I would not be able to pursue my chosen, office-based profession. My health is a constant battle. It has got worse, not better and the prognosis is not encouraging. I had to reassess my life and find new goals, aspirations and a way of earning a living.

As well as the professional challenges, there were health and wellbeing ones. I needed to find ways to manage my increasing pain. From the start, I wanted to avoid being reliant on painkillers and instead explore more natural or alternative ways. Painkillers have a short, effective time period, after which they just don’t work any more.

After spending a lot of time researching and undergoing many operations, it was clear to me that, to manage the pain,

I would have to take a more proactive approach. Research shows that those who suffer chronic pain need to do regular daily exercise and activity to help them manage their pain. The old approach of resting, being immobile and taking painkillers doesn’t work. Dealing with chronic pain is a physical and psychological challenge and exercise plays a big role in helping to balance the dynamic.

And that’s where cycling came inCulturally, exercise for many people is a chore and amounts to no more than walking to the car. So, these people cannot understand the concept. However, exercise not only works but is now endorsed by many experts practising in the area of chronic pain. It is also now written in the UK’s National Health Service guidance for chronic pain sufferers.

The bottom line is, if I didn’t ride every day I would not be able to get through the day. When I can, I go to the Alps and ride – the physical and psychological benefits are immense. Again, some people don’t understand that either, but, as I always reply, for me, every day is a mountain I have to climb!

One frustration (besides often being the only girl on the club runs) was how poorly made cycling caps are. I started to research the humble casquette, always paying close attention to its history, and what works beautifully but also what could work better. Out of this endeavour, I launched the tic brand.

This was not a business idea born from a plan with numbers to support, but an idea based on rider experience and the need to find a new direction in managing my chronic pain.

Most importantly, it meant I could work in a way that is more amenable to my state of health. It’s not really possible in a

conventional working environment to stop, go and stretch or just lie on the floor.

Plus, Cambridge has a big cycling culture and a historic tailoring heritage. Therefore, we have a lovely fit between what and how we design and make and where we make it.

It meant I had to refine my sewing skills. I worked alongside seamstresses and milliners to acquire the additional knowledge and set out to produce the finest handmade cycling caps.

From the unprompted customer feedback we have received, the effort has paid off. People love the idea of something being handmade for them. Craft and precision are inherent in the history of the bicycle making process, so a lot of keen riders appreciate the value that comes with something beautifully made and not mass produced.

All this has opened up another avenueI am very passionate about promoting the benefits of cycling as a management tool for chronic pain, as it has been a lifesaver for me. If I can help improve the quality of life of other sufferers, then I will feel that this life-changing ordeal has not been without one positive.

I have launched a campaign called 1in7. One in seven people in the UK alone suffer from chronic pain – that is a lot of people – and it costs the country a lot of money in working days lost due to sickness. And support for sufferers in the UK is at best minimal. tic has launched a special edition 1in7 cycling cap to help promote the initiative. Some of the proceeds from the sale of each cap will be donated towards critical research.

I hope this initiative will raise awareness so we can help those sufferers who feel unsupported, and that there are possibilities to manage their chronic pain and regain some quality of life.

The road to a better life

The bottom line is, if I didn’t ride

every day I would not be able to get through the day

Daphne Kaufhold has been a keen road cyclist for many years, but never thought that her love of the sport would end up having such a significant role in her life and wellbeing.

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TALKBACK INSIGHT

There is a lot of confusing information around at the moment suggesting new ways to

“cure” non-specific low back pain. The article published in the Daily Mail health supplement on Tuesday 28 July 2015 and the reactions to it in the comment section got me thinking.

As a healthcare practitioner, I believe that the interplay between body and mind is a critical factor in resolving chronic pain. I worked as a Dance and Movement university lecturer in the UK for several years, and I researched human body movement. What I learned then was the value of extending my teaching of movement techniques by including the importance of mental attitude. Sports psychologists tell a similar story: what makes a top sportsperson is a combination of physical prowess and mental attitude.

Let’s start at the beginning: what is chronic low back pain? Chronic low back pain (LBP) is pain that has persisted for more than three months – this differs from back pain evident for less than three months, which is referred to as acute. We expect the body to heal itself naturally in the short term. Appropriate medical intervention such as painkillers, or in some cases surgery, may be required to help the healing process.

DistressingBut when back pain becomes chronic, this signals either that the back has not healed itself or that the pain is caused by nerve pathways in the brain and not by abnormalities in the back itself. When medical practitioners cannot find anything wrong or find only abnormalities that are just as common in people with no pain, this can cause confusion about what is wrong. Not having a well-defined abnormality in the back can be distressing and it may seem that the pain is not properly acknowledged or recognised. It can then be difficult to say to family and friends, who are naturally concerned, that the pain is due to an imbalance in brain nerve pathways.

But when medical screening rules out serious problems, then it is important to look for causes of that imbalance in the autonomic nervous system. In simple terms, the autonomic nervous system has two modes of operation and if they are not in balance, the body may experience pain even if it has no abnormalities or has healed itself from an acute injury. This pain is just as real and can be every bit as severe as pain from acute injury.

The balance of the autonomic nervous system can be affected by many things, in particular

stress. As the nervous system is operated unconsciously, it may require a different approach from the conventional biomedical one to re-balance it: mental attitude plays a part.

In order to rebalance the autonomic nervous system, we need to locate sources of stress in our lives (which are not always easy to recognise) and to uncover triggers that might perpetuate symptoms. This will help with pain resolution as well as improving stress resilience, which can lead to life-changing results.

Improve confidencePain cannot be seen; it is experienced. This means that sometimes the patient becomes so concerned about convincing others that their pain is real that this becomes counterproductive. A more useful activity is to try to identify sources of stress: family, workplace, adverse childhood experience, traumatic events, excessive anxiety, depression.

Another useful approach is to work directly with the body. When someone arrives at my studio with LBP, they are assessed to see what movement range they have. As a movement specialist I teach gentle, adapted Pilates-based movement to free up the body where it has restrictions, using particular movements to strengthen muscles that may have been neglected. The intention is to improve confidence in moving and to extend the range of pain-free movement. At the same time, deep breathing techniques are introduced to stimulate the intercostal muscles in the ribcage.

Significantly, most people experiencing chronic LBP can breathe in for only two, or maybe three seconds. Over time it becomes more normal for them to breathe in for up to five seconds. As each person is different, they set their breathing goal according to their preference, for any number of seconds up to eight. Apart from activating and strengthening the ribcage muscles, deep breathing can stimulate self-healing activity in the body through the parasympathetic nervous system. There is considerable evidence that health professionals teach deep breathing as a useful somatic tool to reduce back pain.

All of my patients complete a Roland Morris questionnaire during or after their first session. This provides a means of measuring practical improvements as the pain diminishes. A quantitative measure of this kind is helpful, as it

ABOUT THE AUTHOR

Mags Clark-Smith is a Pain Relief Movement Specialist in Ireland with more than 20 years’ experience of lecturing, educating health professionals and treating patients. She runs an educational programme to resolve chronic pain – visit www.resolvingchronicpain.com. Mags is on the Advisory Board of SIRPA, is a UCC Neuroscience Researcher and involved in TMS Wiki research.

Why would anyone think low back pain is in your head?

When back pain becomes chronic, this

signals either that the back

has not healed itself or that the pain is caused

by nerve pathways in the

brain...

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TALKBACK l ISSUE 4 2015

TALKBACK INSIGHT 19

allows us to measure a patient’s improvement, which may increase their motivation. The Resolving Chronic Pain programme, which I teach, is an evidence-based path towards the resolution of chronic pain. Other psychophysiologic disorder practitioners adopt similar approaches.

Is back pain in your head? No it is not, and the Daily Mail was provocative and misleading to use such a headline. In the case study that the Daily Mail reported on, did Marie Lovell get rid of her pain by changing her mental attitude and improving her resilience to stress? Yes she did. I have met Marie and she speaks eloquently about the process. Is there gathering evidence that back pain can be treated by re-balancing the autonomic nervous system? Yes, absolutely.

In some respects, this is groundbreaking. It might explain why surgery can be hit or miss, why some patients given the same treatment respond positively and others don’t. It highlights the critical nature of the therapeutic relationship. In other respects it fits with what many people already intuitively believe – that we need time off from our phones and social media, that we need to take responsibility for our own health, nutrition and exercise. We know that we need to find time to process our thoughts and to relax. Neurophysiology provides us with evidence that back pain may be the cost we pay if we don’t listen to our intuition.

REFERENCES:1 www.dailymail.co.uk/health/article-3176485/

Is-pain-mind-Physical-pain-psychological-root-required-different-kind-treatment.html

2 Learned Optimism Martin Seligman 1990, Sport and Exercise Psychology: A critical Introduction Aidan Moran 2004

3 The Healing Power of the Breath. Richard P Brown MD & Patricia L Gerberg, MD. 2012 Pilates-Based Therapeutic Exercise. Rydeard R et al. Journal of Orthopaedic & Sports Physical Therapy Vol : Issue 7: Pages 472-484

4 TMS Wiki (www.tmswiki.org): Clarke, Clark-Smith, Hanscom, Oldfield, Schubiner.

5 Meaning, Medicine and the ‘Placebo Effect’. Daniel Moerman; Cambridge University Press 2002

Why would anyone think low back pain is in your head?

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TALKBACK RESEARCH

IntroductionThe ATLAS study has shown that both the Alexander Technique and acupuncture led to a clinically significant long-term decrease in chronic neck pain.3 This is good news because conventional treatment methods for chronic neck pain are acknowledged to have limited success.4

How was the study conducted?The ATLAS (Alexander Technique Lessons or Acupuncture Sessions) trial was carried out by researchers in the Department of Health Sciences at the University of York and funded by Arthritis Research UK. A total of 517 patients with chronic neck pain (pain that had persisted for three months or more) were recruited from GP practices in Leeds, Manchester, Sheffield and York. The average duration of neck pain turned out to be six years, so this was a particularly challenging population to be able to help.

They were randomly allocated to one of three groups that offered: l twenty one-to-one, 30-minute Alexander Technique lessons (along with continuing usual NHS care), orl twelve 50-minute acupuncture sessions based on traditional Chinese medical theory (along with continuing NHS usual care), orl continuing usual NHS care alone.

The Alexander lessons and acupuncture sessions were delivered within the first five months or so of the beginning of the trial. For all three groups, usual NHS care continued throughout the 12 months of the study and included prescribed medications and visits to GPs, physiotherapists and other healthcare

professionals. It is important to note that the trial was not designed to be a comparison of Alexander lessons and acupuncture; instead, it evaluated the effectiveness of Alexander lessons compared with usual care alone and of acupuncture compared with usual care alone.

What were the findings? Participants in the groups that attended either the one-to-one Alexander lessons or the acupuncture sessions had, on average, nearly a third less pain and disability at the end of the trial than at the start 12 months previously. These reductions in pain and associated disability (31% for those taking Alexander lessons and 32% for those receiving acupuncture) exceeded the threshold of a 25% reduction often used to determine whether improvements are clinically meaningful. Furthermore, when comparing the benefits of Alexander lessons or acupuncture with usual care alone, the reductions in pain and disability were also found to be statistically significant.

The study also found that people’s confidence in their own ability to manage or reduce their pain without using medication (self-efficacy) increased in the groups attending Alexander lessons or acupuncture sessions, and much more so than in the group who received usual care alone. These increases in self-efficacy were associated with a greater reduction in pain and associated disability. The findings are consistent with the general view that approaches that empower people to take better care of themselves are more likely to be effective. In these times of an ageing population and ever tighter healthcare budgets, effective approaches such as these that include self-care are especially welcome.

New hope for people who suffer from neck painNeck pain is the fourth largest cause of disability worldwide and two out of three of us will suffer with it at some point in our lives.1,2 A recent randomised clinical trial has shown that two forms of complementary healthcare, lessons in the Alexander Technique and acupuncture, can each provide real benefit. The new study, called ATLAS, is published in the November issue of the prestigious Annals of Internal Medicine. Here, three authors of the ATLAS publication describe the study findings and the way that Alexander lessons or acupuncture may be able to help people with chronic neck pain.

ABOUT THE AUTHORS

Julia Woodman BSc, PhD, MSTAT and Kathleen Ballard BSc, PhD, MSTAT are both Alexander Technique teachers and members of the Research Group of the Society of Teachers of the Alexander Technique. Hugh MacPherson BSc, PhD, MBAcC was the Principal Investigator of the ATLAS trial and is in practice as an acupuncturist.

Julia Woodman, Kathleen Ballard and Hugh MacPherson

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TALKBACK RESEARCH

Why else might these ‘new’ approaches be needed?Faced with pain, our natural tendency is to look for quick and easy solutions, such as painkillers or rest, not realising that the underlying cause of our problems may be ourselves, the way we go about our everyday activities and react to the world. Neck pain is often caused by poor postural and movement habits, rather than by serious underlying disease or injury.

Conventional medical treatment such as painkillers can be very effective for reducing neck pain when it first occurs, but in some individuals the symptoms persist and the problem becomes chronic. Subtle changes begin in the muscles and other soft tissues of the neck, changes that provoke continuing neck tension and pain4 and become increasingly difficult to reverse as time passes.

The people who participated in the ATLAS trial had already experienced neck pain for an average of six years and it is very encouraging that they were still able to gain significant benefit from their Alexander lessons or acupuncture sessions. Nevertheless, the sooner that effective help is sought, and the greater the range of effective options to choose from, the better.

How might these approaches work? Chronic neck pain is considered a complex condition and several aspects may need to be dealt with in order to manage it. These may include an individual’s habitual responses to pain-causing or other unwelcome stimuli, plus the harmful influence of poor body awareness on general co-ordination and the functioning of postural support and balance systems.

The Alexander Technique is a self-care method that helps people deal with these and related issues. It is taught in practical lessons, usually one-to-one, involving spoken and hands-on guidance. During lessons, people are helped to become more body aware, improve their co-ordination, to observe and improve the functioning of their postural support and balance systems, and discover how to reduce those harmful postural and thinking habits that can contribute to pain, tension and stress. Learning happens through the practical experience of lessons (in much the same way as learning to ride a bicycle or drive a car) and by discovering and using the basic Alexander thinking skills that can

be carried through into the rest of life. When people resolve to apply the Technique in their daily lives they can be inspired and enabled to make beneficial long-term changes to the way they carry out their everyday activities, including working at a computer, walking, sitting or standing; and help themselves avoid, or at least reduce, neck pain.

Acupuncture can relieve pain by stimulating the body’s own pain-relieving and self-healing functions. Acupuncture is based on the insertion of needles at carefully chosen points to trigger specific desired effects. Longer-term effects are associated with additional components of the therapy, such as diagnosis-based lifestyle advice.

Is there other research showing that these approaches are effective?The ATLAS results build on the existing clinical evidence base for these two approaches with respect to chronic musculoskeletal pain conditions. There are now several large randomised controlled trials that show the long-term benefit of Alexander lessons or acupuncture for people with chronic neck or back pain.3,5,6 Other research suggests that Alexander lessons can be effective for a range of health-related conditions,7 and acupuncture has been shown to be effective for low back pain, osteoarthritis and headache/migraine.8

New hope for people who suffer from neck pain

Neck pain is often caused

by poor postural and movement

habits, rather than by serious

underlying disease or

injury

continued on p22

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TALKBACK RESEARCH

Choosing which approach to takeFor individuals who are not able to gain sufficient long-term relief from their neck pain from usual medical treatment, there are now two additional approaches to try, thanks to the ATLAS trial findings. Choosing between Alexander lessons and acupuncture will depend on personal preference as both approaches have been found effective, but someone who is in a lot of pain may prefer to try acupuncture first. Alexander lessons are easier to follow when pain is less severe and are best suited to people with a particular interest in self-care.

These two interventions can be considered complementary in that acupuncture is a therapy with a self-care element, while Alexander lessons are primarily for teaching and learning a self-care method, yet have a therapeutic component. So a third approach may appeal to some people, one which the ATLAS paper suggests deserves study. That is to attend acupuncture sessions for initial pain relief and advice, and then Alexander lessons for life-long skills in self-care that continue pain reduction and help prevent relapses.

Finding a suitable Alexander teacher or acupuncturistIt is important to find someone who is properly trained and insured by checking that they belong to a recognised professional association.

All the Alexander teachers in the ATLAS study belonged to the Society of Teachers of the Alexander Technique (STAT), the largest and longest-established professional association. STAT teachers have completed three years of full-time training and are expected to be committed to their continuing professional development. STAT provides an online directory where a postcode or town can be entered to obtain a list of local teachers. Group workshops or courses can provide a good introduction to the Alexander Technique and to the teacher, whereas one-to-one lessons provide greater

individual support. Prices for individual lessons vary according to location, but typically are between £30 and £50, depending on overhead costs etc, and concessions may be available. Once the basics of the technique have been absorbed from a number of weekly lessons (ideally with a few twice-weekly at the beginning), they can generally become less frequent.

All the acupuncturists in the study belonged to the British Acupuncture Council (BAcC), the largest and longest-established independent professional association. Acupuncturists have completed three years of full-time training and are expected to be committed to their continuing professional development. BAcC provides an online directory where a postcode or town can be entered to obtain a list of local practitioners. Prices vary but typically are between £35 and £45.

Further informationFurther information about the Alexander Technique and how to find a teacher are available at www.alexandertechnique.co.uk. Further information about acupuncture and how to find a practitioner are available at www.acupuncture.org.uk.

Glossary Chronic neck pain: neck pain that has lasted three months or longer.Self-efficacy (in relation to pain): the extent to which people have confidence in their ability to manage or reduce their pain without increasing their medication.Randomised trial: a clinical trial that randomly allocates the participants (by computer) to the different groups to help ensure these are as similar as possible at the beginning of the study, protecting against potential bias in the results.Controlled trial: a clinical trial in which an intervention is compared against another intervention. The second intervention is often standard treatment (e.g. “usual NHS care”). A controlled trial allows the researchers to discover how much of any benefit is due to the intervention being tested and not to the natural tendency for people to gradually get better over time.

REFERENCES:1 Hoy D, March L, Woolf A, Blyth F, Brooks P, Smith E, et al. The global burden of neck pain: estimates from the global burden of disease

2010 study. Annals of Rheumatic Diseases 2014;73:1309–15.2 Patient UK. Available at: http://patient.info/doctor/neck-pain-cervicalgia-and-torticollis.3 MacPherson H, Tilbrook H, Richmond S, Woodman J, Ballard K, Atkin K, et al. Alexander Technique lessons or acupuncture sessions for

persons with chronic neck pain: A randomized trial. Annals of Internal Medicine 2015;163:653-62. 4 Jull G, Sterling M, Falla D, Treleaven J, O’Leary S. Whiplash, Headache and Neck Pain. Edinburgh, UK: Churchill Livingston; Elsevier; 2008.5 Little P, Lewith G, Webley F, Evans M, Beattie A, Middleton K, Barnett J, Ballard K, et al. Randomised controlled trial of Alexander technique

lessons, exercise, and massage (ATEAM) for chronic and recurrent back pain. British Medical Journal. 2008;337:a884.6 Thomas KJ, MacPherson H, Thorpe L, Brazier J, Fitter M, Campbell MJ, et al. Randomised controlled trial of a short course of traditional

acupuncture compared with usual care for persistent non-specific low back pain. BMJ. 2006 Sep 23;333:623–6.7 Woodman JP, Moore NR. Evidence for the effectiveness of Alexander Technique lessons in medical and health-related conditions: a

systematic review. International Journal of Clinical Practice 2012;66:98–112.8 Vickers AJ, Cronin AM, Maschino AC, Lewith G, MacPherson H, Foster NE, et al. Acupuncture for chronic pain: Individual patient data meta-

analysis Archives Internal Medicine 2012;172:1444−53.

Chronic neck pain is considered a complex

condition and several aspects

may need to be dealt with

in order to manage it

Choosing between

Alexander lessons and acupuncture will depend on personal preference

as both approaches have been

found effective

from p21

TALKBACK EDUCATION 23

Nodoff!10 good reasons to get enough sleep01 brain:justonenightofsleepdeprivationis

linkedwithsignsofbraintissuelossandcausesasmuchcognitiveimpairmentasbeingoverthedrinkdrivelimit.

02 wellbeing:sleeplossproducesapathy,irritability,weepiness,impatience,anger,andflattenedresponses.Peoplewithinsomniaare10xaslikelytodevelopdepressionand17xaslikelytohavesignificantanxiety.

03 cardiovascular:sleepinglessthansixhoursanightisassociatedwithfourfoldhigherstrokeriskformiddle-andolder-agedpeopleanda48%higherchanceofdevelopingordyingfromheartdisease.

04 back pain:theworld’sleadingcauseofdisability,backpainisstronglylinkedtoinsomnia.Twothirdsofpeoplewithbackpainalsohaveinsomnia.Researchhasrevealedthatinsomniapredictswhowilldevelopbackpaininthefuture,butnotviceversa.

05 obesity:sleephelpstoregulatethehormonesthatgovernappetite.Sleeplossincreaseshunger,portionsize,andpreferenceforhigh-caloriefoods,withtheresultingriskofobesity.

06 infection:sleepingfewerthansevenhoursanightisassociatedwithatripledriskofcomingdownwithacold.Infection-fightingantibodiesandcellsarereducedduringperiodswhenwedon’tgetenoughsleep.

07 cancer:chronicsleepdeprivation(lessthansixhoursanight)resultsinchangestomorethan700genesandislinkedtoa50%higherriskofcolorectalcancers.

08 fertility:sleepregulatesthesexhormones.Sleepdeprivationislinkedtoreducedsexdrive,erectiledysfunctionandinfertility.

09 safety:sleepinsufficiencyislinkedtomotorvehiclecrashes,industrialdisasters,andmedicalandotheroccupationalerrors.Gettingsixorfewerhoursofsleeptriplesyourriskofdrowsy,driving-relatedaccidents.

10 performance:well-restedtennisplayersgeta42%boostinhittingaccuracyduringtraining.Swisstennischamp,RogerFederer,whowonWimbledonarecordseventimes,hassaid:“IfIdon’tsleep11-12hoursaday,it’snotright!”

TALKBACK l ISSUE 4 2015

24 TALKBACK NEWS

TALKBACK l ISSUE 3 2015

Would you like to:l become an advisor on research steering committeesl give independent feedback on clinical trial protocolsl participate in the development of new medical devicesl take part in research questionnaires and surveys?

If you suffer from back pain and would like to get involved with research, please visit www.backcare.org.uk/research

participate!Calling all BackCare members!