21 minute read
skiing accident
Jessica is a 51-year-old mum with a large family and a physically active lifestyle who became affected by chronic pain in her neck, resulting from a skiing accident in 2017.
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{ON THIS occasion, I was going much faster than I was comfortable with, and while taking a corner, I hit some ice and had a wipe-out fall. I remember at the time my neck flicking backwards and really smacking my head on the ice. I lay there for a minute terrified that I had broken something. I was literally seeing stars and my ears were ringing. In the ridiculous way that you do when you trip up, I pulled myself up as soon as I could, desperate to find out if I was still in one piece and I could move everything. I was helped to the side of the slope and spent 10 minutes collecting myself before attempting to limp down the mountain.
That was the end of my skiing for the week and my neck was stiff and painful, but by the time I returned to the UK I felt pretty much normal and carried on with life
as usual for the next six months or so.
I then started to become aware of a deep aching pain in my neck that would not go away. The pain crept down my neck and into my left shoulder and arm. At the time I didn’t know it, but this was nerve pain that would eventually wake me every night, bang on 2am!
Initially, the pain would come and go and I would dose up on over-the-counter painkillers, but over time I found that it was really limiting the amount of exercise I was able to do. It also made me extremely grumpy and generally out of sorts. My sleep at night was very disturbed as I had pain down my left side and could not get comfortable. It led to me feeling low and miserable and hugely affected me enjoying time with my family, as all I really wanted to do was go and lie on my bed. When you are suffering chronic pain, it affects the whole family unit as you just aren’t yourself and its hard to feel excited or show interest and get involved with your children when you feel constant pain. It’s like your attention is somewhere else the whole time.
Brain scan
It was when my husband pointed out the dangerously high number of empty painkiller boxes that were appearing in the bathroom bin that I had to address the situation. I made an appointment with a spine surgeon and had a brain scan and MRI of different cross-sections of my neck and back.
What the images showed was that my C4, C5 and partially my C6 cervical disks had massive degeneration, were bulging, and pretty much touching the spinal cord. Typically, this type of injury can take some time to start hurting, after the initial impact, so it came as no surprise to the consultant that my fall had taken place six months before. My doctor presented me with a range of options. I was a candidate for an operation called an ACDF (anterior cervical discectomy and fusion) which involves slicing open the front of your neck to access the spine, removing the damaged disks and replacing them with artificial ones that are held in place by a titanium cage. While generally successful and relatively commonly conducted on professional sportsmen (especially rugby players), there is risk to your vocal cords – and every operation involving the spinal cord is a big deal.
Steroids
The recuperation time from the op was also a consideration. Before I took this route, he recommended that I try transforaminal epidurals of steroids. I did this for about six months until the specialist that I was seeing said there was no point as further injections would not help and advised that I went ahead with the operation. These injections were a pain as I was sedated first and had to spend a day in hospital every few months and I had horrible brain fog from the anaesthetic for a day or two afterwards. I saw a specialist consultant physiotherapist but any manipulation or pressure upon the area made the pain worse. It was at this point I tried medical cannabis medicine, really as a last attempt to find a solution before undergoing the operation.
Getting your treatment right takes a while and for me it was a balancing act of getting the correct percentage of THC and CBD in an oil, specially mixed for me and then vaping an indica flower at night and, if additional pain relief was needed in the day, a sativa blend. Though this became unnecessary once I was taking the oil three times a day.
I have now reached a “sweet point” in terms of my dosage, which I feel is just right and I am living pain-free at the moment. I am able to run, weight train and do yoga again and feel in peak fitness. But I do listen to my body and never overdo things and check in with the practice nurse at the clinic every couple of weeks.” | Cannabis plant
Register for our FREE webinar
If you would like to hear Dr Ordman in the forthcoming BackCare webinar and ask him any questions, please register for this free event on Tuesday 25 May 19:00 - 20:30. This webinar will be of interest to healthcare providers and anyone suffering from back pain whether it is a primary condition or a secondary symptom of a more complex pain condition such as MS, fibromyalgia or osteoarthritis.
To register: https://www. eventbrite.co.uk/e/discussingback-pain-and-cannabismedicinestickets-146736608145.
Chronic back pain: a frequently overlooked symptom of MS
Multiple sclerosis (MS) is a complex and personal condition. Rarely are two patients’ experiences identical which makes treating the condition all the more difficult. SOPHIE HAYES reports.
MS is a lifelong condition which primarily affects the brain and the spinal cord. It is characterised by unpredictable inflammation and scarring of the central nervous system. The most common symptoms include fatigue, muscle stiffness and spasm, spasticity (increased muscle tone), problems with cognition, neuropathic pain (experienced as burning, pins and needles, squeezing, hugging or pressure), problems with balance and co-ordination and back and joint pain.
Back pain experienced by individuals living with MS is often an indirect symptom resulting from the condition. The disrupted messaging causes mobility difficulties which, in combination with muscle spasms and muscle tone changes, puts pressure on the lower back causing stiffness and pain. Back pain can also be a result of the disrupted or misdirected pain signalling.
Pain in MS comes from different reasons. Everyone has different symptoms, lifestyles and coping strategies. There are a number of different technique combinations that can be curated in order to obtain optimum symptom management.
Symptoms such as chronic back pain in MS can have a significant impact on daily living, relationships, social roles and patients’ working lives. It is understandable that many people who live with chronic conditions find there is an impact on their psychological wellbeing. This can result in depression and anxiety. There are also many psychosocial factors that influence a patient’s adjustment to chronic pain. These include painrelated beliefs, coping behaviours and family members’ responses to pain behaviours.
Managing such a complex range of symptoms often requires a multidisciplinary approach encompassing practices that can be used alongside prescribed medications. Introducing these methods can give those living with MS a greater sense of control over managing and treating their pain for both short and long-term. Pain management strategies are by no means a “one size fits all” and should be discussed with a patient’s clinical team.
Short-term pain management
Short-term pain management techniques are those intended to provide relief in the moment rather than for any extended period of time. Research into a number of these practices is still ongoing.
Transcutaneous electrical nerve stimulation:
When the TENS machine is switched on, small electrical impulses are delivered to the area, such as the lower back. These electrical impulses can reduce the pain signals going to the spinal cord and brain, distracting the nociceptors, helping to relieve pain and relax the muscles.
Cooling and/or heat therapy: 60-80% of the multiple sclerosis patients present adverse clinical symptoms when their body temperature is increased. This can be the result of over-exertion or factors as simple as hot weather, or a bath that is too hot.
Raised temperatures stop nerve fibres from working properly. When the body overheats, the electrical impulses, or messages, find it harder to pass along the nerve. For individuals living with MS, these nerve fibres are already damaged, so these messages may not get through at all. This can result in increased pain levels.
Simple actions such as drinking cool liquids, sucking on ice cubes/lollies, taking a cool bath or sitting in front of an open window or fan can help provide some relief. Conversely, some patients experience mobility issues, spasms or muscle tightness if temperatures are too low. In these cases, hot drinks, hot food and warmer but loose items of clothing can be helpful.
Complementary therapies: These are used alongside regular healthcare practice. It is not advised that these are used in replacement of the advice provided by an individual’s clinical team.
Many living with MS have taken this approach, and find benefit from visiting chiropractors, osteopaths, going for massages or acupuncture, and attending yoga or meditation classes.
The National Institute of Clinical Excellence states that complementary therapies such as these can be helpful for individuals living with MS in terms of improving a general sense of wellbeing. However, it does highlight that there is not enough research evidence.
Long-term pain management
Long-term pain management aims to stabilise and manage pain levels over a longer period of time and are often focused on how we manage our physical and mental health alongside pain and other symptoms.
Physiotherapy exercises: The key to longterm back pain management is found to be movement. The less movement, the less synovial fluid is produced. This fluid cushions the ends of bones and acts as a shock absorber. Therefore, it reduces friction when joints move. If these joints stop being used, synovial fluid stops beings produced. This leads to significantly reduced ranges of movement and subsequently, decreases mobility, hence increased back pain. Another cause of back pain in MS is determined by spasticity or increased muscle tone. Physiotherapy is considered to be fundamental in managing prevention of spasticity associated secondary complications, including back pain.
Results from randomised controlled clinical trials of physiotherapy exercise programmes in MS have demonstrated benefits in muscle strength, cardiovascular fitness, aerobic thresholds, activity levels and functional improvements, such as walking ability. A comprehensive programme that includes strengthening and stretching exercises will help to ensure the core muscles are strong enough to support the individual’s weight and allow for greater range of movement for a longer period of time. Supportive braces: These are likely to be introduced following an orthotic review and can include a wide range of braces, splints and supports.
One example of these supportive braces is a thoracic lumbar sacral orthotic brace. When worn correctly they will offload weight from the spinal vertebrae, which can relieve some of the pain experienced by the individual. These are typically introduced in the later stages of progressive MS, when an individual wishes to exercise other parts of their body but have difficulty controlling their core muscles.
24hr postural management: In the latest stage of progressive MS, significantly reduced mobility will be a key factor in the management of back pain. Ensuring regular position changes throughout the day will help manage this. This may require the help of carers and equipment such as hoists and supportive pillows to reposition an individual every 3-4 hours. This will ensure that muscles do not become too stiff and joints do not become “locked”.
Psychotherapy: How an individual living with MS relates to their pain can be a key factor in not only the management of it, but the experience of it. Having psychological support as part of an individual’s care regime can have a significant impact on their experience of pain.
Cognitive behavioural therapy: CBT is a type of talking therapy based on the idea that Above: carefully planning an effective and varied care regime, can help the patient regain a sense of control over their symptoms
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Disrupted messaging causes mobility difficulties which, in combination with muscle spasms and muscle tone changes, puts pressure on the lower back causing stiffness and pain
< from p17 thoughts, feelings, what we do and how are bodies feel are all connected. CBT proposes that if we change just one of these aspects, we can change the rest over time. CBT practice encourages individuals to practise noticing and eventually changing problematic behaviour or thinking patterns.
Studies have shown improvements in pain severity, pain interference and emotional wellbeing, suggesting that including CBT can be beneficial for persons living with MS.
Newly available medicines
cannabis medicines became legal to prescribe in November 2018. These medicines are currently available primarily via private clinics, although Sativex is available on prescription via the NHS for spasticity in MS.
Cannabis medicines can be an effective symptom management tool when added to a care regime. Cannabis flowers grow tiny hairs called trichomes, which themselves contain hundreds of different chemical compounds. The most common are two of a family of compounds called cannabinoids, THC and CBD. These two compounds are the most researched and are each known to have a multitude of medical actions and play a role in treating pain.
These cannabinoids interact with our body’s own endo-cannabinoid system (ECS). The ECS is a system of receptors, situated on certain cells throughout the body. To date, we have identified two key ECS receptors; CB1 and CB2. Humans naturally produce their own endocannabinoids. Two examples of this are anandamide and 2-AG. These receptors and endo-cannabinoids make up the ECS. The ECS is involved in regulating numerous physiological functions including (but not limited to) motor co-ordination, neuroprotection, pain control, appetite stimulation and regulating our immune systems.
Endo-cannabinoids such as anandamide are produced through activities such as
exercise, but for those living with chronic conditions, this is more difficult to produce naturally. It is more difficult to regulate all body systems, and cannabis medicines can be useful supplements to these essential naturally produced compounds.
THC has been proven to alleviate neuropathic and inflammatory pain caused by multiple sclerosis by reducing pain signalling and acting as an anti-inflammatory.
CBD is an effective muscle relaxant making movement more comfortable and therefore enabling individuals to be able to engage with physiotherapy exercises or complementary therapies such as yoga, all of which contribute to maintaining muscle strength and tone.
Better pain management, with fewer side effects than opioid medications, can result in higher quality sleep. This, coupled with the mood stabilisation effect of some cannabis medicines, can help build emotional resilience and empower individuals to manage symptoms such as anxiety and even enable them to engage with mindfulness or meditation techniques as part of a holistic approach to back pain management.
The goal of carefully planning and sticking to an effective and varied care regime is to help the patient regain a sense of control over their symptoms. In order for this regime to be sustainable, it has to be right for their lifestyle. When considering how best to manage back pain, or other symptoms associated with multiple sclerosis, it is always important to do this in collaboration with your clinical care team.
A patient’s experience of cannabinoids
JASMIN was diagnosed with multiple sclerosis in 2015. During a holiday to Morocco, where the temperatures reached up to 44 degrees centigrade, she noticed she was experiencing symptoms she had never had before. “I lost hearing in my right ear and would get a painful, vibrating sensation in my spinal cord when I moved my neck. I was exhausted all the time. It would get to four o’clock in the afternoon and I would need to take a nap, I knew something wasn’t right.”
Jasmin was referred by her GP to the ear, nose and throat clinic to investigate her new hearing loss. When there was no evidence of a burst eardrum, she was sent for a brain scan to check if there was an internal cause. “They identified lesions straight away.”
Jasmin is in the early stages of MS. While she does live with symptoms such as fatigue, muscle tightness, back pain and brain fog, she is still self-employed, working full time but flexible hours as founder of CBD company OhanaCBD. She is also expecting a baby very soon. “My hips are now very painful at this late stage of my pregnancy, but cannabinoids really help me manage.”
Jasmine is one of many MS patients who has found benefit from compounds found in the cannabis plant called cannabinoids and is a vocal advocate of the benefits of cannabinoids in combination with non-pharmacological methods such as yoga, meditation, regular exercise, a plant based, gluten free diet and ayurvedic supplements in the management of her MS symptoms.
“Under the guidance of your healthcare professional, it is vital that patients empower themselves with the knowledge about their condition and how well traditional medicine and complementary medicines can work together. There is no ‘one size fits all’, you have to find what works best for you.”
n Sophie Hayes is a registered nurse who has specialised in Emergency and Acute Medicine. She has worked in A&E in the Royal Sussex County Hospital, St Thomas’s Hospital and in Critical Care at Kings College Hospital. In 2019, she cofounded and launched the Nurses’ Arm of CPASS (Cannabis Patient Advocacy and Support Services) at the Royal College of Nursing.
Using oxygen therapy to reduce pain swelling and inflammation
At BackCare, we understand that people often live with back pain as a consequence of their lifestyle or other underlying conditions. PAUL BISHOP from Herts MS Therapy Centre, discusses his experience of back pain and how people with multiple sclerosis (MS) and back problems can benefit from oxygen therapy provided by an MS Therapy Centre.
Way back when… my father, a keen tennis player when he was a young man in the late 1940s and early 50s, thought Lew Hoad was the best player ever. Australian Hoad was world number 1 in 1953 and 1956 and had a game based on strength and power. However, he was plagued by serious back problems throughout his career.
Ironically, the problem was self-inflicted. In 1954, Hoad had devised a weightlifting exercise which involved doing push-ups with 50lb weights on his back.
By the time I was aware of Hoad, watching him on TV at Wimbledon in 1968, he was a spent force and was drinking heavily to ease the pain. My father learnt that this former giant of the game was human and I learnt about back pain.
Some years later I tweaked my lower back playing tennis but it was only a minor injury. However, one-third of the adult population in the UK suffer from back pain. Some live with back pain caused through injury and wear and tear while others live with back pain because of other underlying and serious health conditions. One such condition is MS – a lifelong disease of the central nervous system, which has, as yet, no known cure. It is the most common neurological condition among young adults today.
Some 100,000 people are living with MS in the UK today. One of those is Barbara Cowan, from Stotfold, near Hitchin. Barbara has been receiving oxygen treatment at Herts MS Therapy Centre in Letchworth since it opened 32 years ago. “I have foot drop that causes my left foot to drag and this causes considerable pain in my back and affects my balance as well. As a consequence, I have needed to walk with a stick for the past two years.
“The regular oxygen therapy I receive has helped relieve the pain and negative sensations in my back and legs,” Barbara said.
In oxygen therapy, pure oxygen is breathed through a mask under pressure in a specially constructed chamber. Many people using oxygen therapy find it can help reduce their pain, decrease swelling and inflammation, boost energy and improve vision, for example. Our chamber in Letchworth, Herts, is like a room inside a large steel tube that can be sealed and pressurised. It is large enough to seat up to seven people.
People living with pain and symptoms related to MS, Parkinson’s disease, chronic fatigue syndrome, ME, fibromyalgia, leg ulcers, sleep apnoea, long Covid, and cancer, can often benefit from oxygen therapy. There are a large number of MS therapy centres in the UK all operating as charities. www.hertsmstherapy.org.uk www.msntc.org.uk/find-a-centre
Let us know
If you have a story for ‘Talking Backs’, please contact: media@backcare.org.uk
Where there is a will there is a way
Image: katemangostar/freepik
A gift in your will can make a huge difference to someone living with back pain BACK pain is often seen as the Cinderella condition, too often ignored and neglected and far too easy to brush under the carpet. Like Cinderella, back pain is invisible, but it does affect eight out of 10 people at some stage of their lives, often wreaking havoc in the process. A gift in your will can make a huge difference and help to transform the lives of people who are tormented by back pain.
Denice Logan Rose, executive director of BackCare, said: “We have people’s backs, quite literally. At BackCare, we work tirelessly to help prevent back injury through education and provide practical and emotional support to those living with back pain. While BackCare is a small charity, we are a national one, with a wide remit, and legacies are crucial to the funding of our work.”
There are two main ways you can leave a legacy to BackCare – a pecuniary bequest (a gift of a specified amount of money) and a residuary bequest (a gift of the balance of your estate, or part of it, once all other gifts have been distributed). Many people choose to leave a residuary bequest to their favourite charity or charities because this is a gift which is least affected by inflation. l If you would like further information about leaving a lasting legacy to BackCare, please contact: Legacies@backcare.org. uk or phone 0208 977 5474.
CSP to exclude spinal injections from liability insurance cover
FROM 1 July the Chartered Society of Physiotherapy (CSP) will be explicitly excluding a number of spinal injection interventions from cover within the CSP professional liability insurance (PLI) scheme. Members who undertake these activities and rely on CSP PLI for their indemnity will need to adjust their practice in order to remain insured.
Therapeutic injection therapy has been within the scope of physiotherapy practice since 1997. CSP adviser Pip White says: “It typically includes injection to the structures of the peripheral skeleton and increasingly, with advances in professional capability, may now include injection to the structures of the spinal skeleton.
All injection therapy carries risk, but the risks for spinal injection interventions are greater.
Pip White adds: “The CSP has taken a pragmatic risk-management decision to be very clear to members that some spinal and other interventions will be explicitly excluded from PLI cover from 1 July this year.”
The explicitly excluded activities will be: regional and general anaesthesia, including peripheral nerve blocks; epidural injections with or without the use of local anaesthetic; spinal and caudal injections; spinal and caudal nerve blocks. www.csp.org.uk
Take part in a research study into chronic pain
COULD you help with this doctoral research?
María de los Angeles Zapata Rodríguez at Heriot-Watt University is undertaking a research project in the intersection of gender and disability in the employment experiences of people in Scotland living with chronic pain (including back pain).
She is interested in hearing from people who are working or looking for employment in STEM careers and living neuropathies etc) or is working as a team leader (in charge of organisational practices) in HR, diversity or occupational health.
María can be contacted by email: mz56@hw.ac.uk or by phone on 07395 390245. TALKBACK l SPRING 2021
