TalkBack, Issue 1 | 2014 (BackCare)

■ NEWS

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

WINTER 2013/14

£2.95 • FREE TO MEMBERS

Insomnia Cause, cure and beyond

John Sarno Godfather of pain recovery

Leading edge Three breakthroughs to kick start 2014

The Charity for Back and Neck Pain www.backcare.org.uk

2 TALKBACK EVENTS

BackCare Events Calendar 2014 BritSpine 2014 1 – 4 APRIL

Biennial Scientific Congress of the British Association of Spine Surgeons, the British Scoliosis Society and the Society for Back Pain Research. University of Warwick. www.britspine.com

Virgin London Marathon 2014 13 APRIL

Join Team BackCare at the world’s largest marathon. You can view our runners’ profiles and make a donation here today: www.bitly.com/team2014

World Health and Safety at Work Day 28 APRIL

BUPA London 10K Challenge 25 MAY

Starts and finishes in St James’s Park, using Green Park as its assembly area. Team BackCare has 10 places available.

Contact events@backcare.org.uk or telephone 020 8977 5474. www.london10000.co.uk

The Back Pain Show 2014 4 – 6 JULY

Proudly sponsored by BackCare, the 2014 event brings together the latest in back care products and techniques in an exciting three-day format. Free tickets at www.backpainshow.co.uk/go/backcare-banner and in next TalkBack! Visit BackCare at Stand B12. Olympia Exhibition Centre, London.

Prudential Ride London 100 9 – 10 AUGUST

One of London’s newest mass-participation fundraisers. Cycling festival featuring 100-mile cycle challenge.

Applicants must be confident cyclists who can ride safely in large groups. Contact events@backcare.org.uk or telephone 020 8977 5474. www.prudentialridelondon.co.uk

Therapy Expo 2014 12 – 13 SEPTEMBER

UK’s dedicated show for Clinic Therapists and Independent Practitioners. Manchester Central.

Visit BackCare at Stand 16. www.therapyexpo.co.uk

British Conference of Acupuncture and Oriental Medicine 26 – 28 SEPTEMBER

Daventry Court Hotel in Rugby

National Back Exchange Annual Conference and Exhibition 29 SEPTEMBER TO 1 OCTOBER

“Outside the box: Broadening horizons” – this is the “must attend” event of the moving and handling calendar.

Hinckley Island Hotel, Leicestershire. www.nationalbackexchange.org

BackCare Awareness Week 2014, “Back in the Office” 6 – 11 OCTOBER

Back pain in office workers will be the theme of our 2014 awareness week. Campaign packs and details of media activities will be released closer to the event.

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TALKBACK WELCOME 3

Welcome

Contents News

With a rather wet and windy winter now retreating, I welcome you to the first issue of 2014. BackCare head office was lucky enough to avoid the widespread flooding, as well as a small tornado that tore roofs off properties in nearby Richmond upon Thames. I hope that you and yours have remained safe amid such turbulence.

In this issue, we bring you extended news coverage featuring an update on BackCare fundraisers, reports on three key breakthroughs in pain medicine research, and our “no-holds-barred” commentary from the NICE guidelines revision process. We also tell you how you can support BackCare at no cost every time you shop online!

I’m starting a new theme of academic poster presentations in this issue that will feature case studies from beyond pain management. The aim of the series is to cultivate an awareness of what pain medicine can look like once we develop beyond pain management thinking. This is a powerful exercise for both patients and practitioners.

Next up, did you know that two-thirds of back pain sufferers are also insomniacs? Our series, “Prevention is better than cure” continues with a bumper episode that explores the relationship between insomnia and back pain. We survey insomnia through the eyes of successive medical models (palliative, management, curative and beyond), with a recipe for tonight’s insomniac.

Finally, through his decades of practice, bestselling books and guiding influence on a new generation of pioneers, Doctor John Sarno has catalysed the evolution of pain medicine. We take a look at the godfather of pain recovery.

As always, we do welcome contributions from our members – whether you have back pain or treat people with back pain, if you can inform and inspire others, we’d like to hear from you. Just drop me an email at yourstory@backcare.org.uk or send us a letter to the usual address.

Don’t forget, we do attend several shows and conferences every year. Why not visit us this year at the Back Pain Show (July, London) and the Therapy Expo event (September, Manchester). Until then, enjoy this magazine and I’ll see you in the next issue.

Dr Adam Al-Kashi Head of Research & Editor of TalkBack

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

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TalkBack is designed by Pages Creative www.pagescreative.co.uk and printed

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4 TALKBACK NEWS

Yoga teacher wins national award SHOPPERS AID CHARITIES

BackCare has joined a charity fundraising scheme that lets online shoppers raise money without incurring any extra cost to themselves.

Winning the 2014 Institute of Fundraising awards for best technology and most committed company, Give As You Live has raised £4.3 million for UK charities through 3,191 trusted outlets including Amazon, Tesco, John Lewis and Marks & Spencer.

Visit www.giveasyoulive. com to join the scheme and raise money for BackCare every time you shop online – the money is donated by the shopping outlets.

Yoga teacher and researcher Alison Trewhela, from Cornwall, has won the 2013 award for “Most Outstanding Contribution to Complementary Therapy” by the Institute for Complementary and Natural Medicine (ICNM) for her Yoga for Healthy Lower Backs (YHLB) programme.

She developed the back pain-specific yoga programme and then demonstrated

its effectiveness and cost-effectiveness in the management of chronic lower back pain through a high-profile clinical trial at York University.

Alison, who belongs to both the Iyengar and British Wheel of Yoga organisations, has now trained close to 300 yoga teachers to be able to deliver the programme exactly as featured in the clinical trial.

Alison Trewhela, far left, at the awards ceremony

Alison says: “The ‘Yoga for Healthy Lower Backs’ (YHLB) 12-week programme is unique in that it is now being shared by many whilst keeping to the evidence-base.”

In the trial, patients on the YHLB programme took three times fewer days off work compared to patients receiving normal GP care. This means that an employer who invests £292 for one member of staff to attend the 12-week programme would save £800 every year thereafter, and since YHLB teaches individuals how to self-manage their long-term physical and mental health, the programme would likely reduce preventable and stress-related illnesses.

Readers can access YHLB resources, including the clinical trial data and a directory of YHLB teachers, online at www.yogaforbacks.co.uk

NICE revises guidelines on back pain treatment The UK’s National Institute for Health and Care Excellence (NICE) is revising its guidelines for the treatment of lower back pain and sciatica.

The first round of consultation sought to establish what should be included in the revised guidelines. A number of organisations participated, including those representing osteopathy, chiropractic, acupuncture, the Alexander technique, yoga, massage, surgery, pharmacology, nursing, research and pain patients. BackCare was among the organisations involved and submitted the following seven abridged comments.

1) Physical factors are only associated with chronic and non-specific back pain in the absence of psychological factors. Clinical evidence tells us that “medically unexplained” or “non-specific” symptoms are significantly more common among patients who believe in physical causes. We would thereby expect existing national health messaging to actually increase back pain prevalence.

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2) Back pain is common to several validated assessments of somatisation and is consistently predicted by psychological factors. The evidence suggests that the physical processes involved in chronic and non-specific back pain are fundamentally stress-induced, as with most headaches.

3) Focus group #4 said, “Psychological interventions do not need to be led by a psychologist.” It is quite alarming to think that psychological interventions are being dispensed like mechanical recipes. Should surgeons lead surgery?

4) The re-emphasis of the Alexander Technique (AT) in the guidelines is to be commended as it has been improperly represented to date. The AT model is fundamentally psychophysical and it has been evidenced to impact psychometrics significantly. It is not merely a postural education.

5) The Danish antibiotics trial did not use an active placebo control. Bioclavid has

very obvious side effects. Without an active placebo control the results absolutely cannot be distinguished from a placebo effect in patients who realised they were in the active group.

6) The stance on smoking cessation should be strengthened by stating specific evidences, namely that (a) back pain treatments statistically fail in smokers, (b) occupational lifting only predicts back pain in smokers, and (c) smoking dependency is correlated detectable psychological dysfunction.

7) If guideline implementation remains poor, even the best guidelines are useless. This process is subject to its weakest link. If GPs happen to constitute the weakest link, this must be remedied in a technical and evidenced-based manner, no less.

Readers can access all comments online: http://guidance.nice.org.uk/CG/ Wave0/681/Scoping

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Runners set their sights on raising money for BackCare DOWNLOAD £120,000

Around 60,000 people have downloaded the BackCare app since its relaunch in collaboration with Simplyhealth on national television in September 2013. The smartphone app is free, but for every download Simplyhealth donates £1 to BackCare; it will continue up to a target of £120,000 or until 30 April, whichever comes first. So there are just weeks to secure the remaining money. Spread the word among your friends, family and social media networks.

(Bonus tip: if you delete the app and download it again, it counts twice – or however many times you do this!)

More than 30 runners have joined Team BackCare to run the Virgin London Marathon

We’d like to acknowledge and thank the courageous individuals who are undertaking challenge events in order to raise money for BackCare.

First up is Pilates instructor and BackCare Professional member Kate Sellars, who is aiming to cover 120km across 10 events this year, including eight 10km races and two half marathons. Her target is to raise £2,000 for BackCare.

See her full list of events and show your support through her Just Giving fundraising page at www.justgiving.com/ Kate-Sellars1.

Owen Copeland will be taking part in the BUPA Great North Run this year, running the half marathon to raise £500 for BackCare. Owen has suffered from back pain for 18 years and is soon due to have his second spinal fusion surgery. You can read more about his story and support

his efforts through his Just Giving page at www.justgiving.com/ owen-copeland.

Alternatively, cheques can be clearly marked as a donation towards a specific fundraiser and sent directly to BackCare head office where we will add the value to their running total.

Finally, more than 30 runners have joined Team BackCare to run the Virgin London Marathon this year. They will collectively be running more than 800 miles to raise money for BackCare.

Just head on over to www.bitly.com/team2014 where you can support the runners.

BackCare’s Lothian branch has already raised £300 for three of our runners. We’d also like to thank the British Acupuncture Society, which is the official sponsor of the 2014 BackCare London Marathon team.

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6 TALKBACK NEWS

Leading edge: breakthroughs in We are awash with new research, but how much of it actually has the power to radically change our understanding? Here, we present three breakthroughs from the latest in pain research to kick-start 2014…

Predicting non-recovery

Every day, 7,000 people in the UK develop chronic back pain. That’s 4% of the population every year. A third of these will never recover.

Researchers at the University of Sydney, Australia, have just published a vital study that reveals factors predicting the development of chronic back pain. The researchers recruited 100 lower back pain patients from physiotherapy clinics in the Sydney metropolitan area (35 men and 65 women; aged 18-75). All had reported a new episode of lower back pain within the previous three months. Those with a history of persistent back pain or other medical illnesses were excluded.

The patients then completed a variety of well-established pain, disability and psychology assessments (including: Visual analogue scale; Orebro Musculoskeletal Pain Screening Questionnaire; Depression Anxiety Stress Scales-21; Roland-Morris Disability Questionnaire; Fear of Pain Questionnaire III; and Tampa Scale for Kinesiophobia). They were then followed up at three and six months to determine whether these clinical measures could shed light on non-recovery.

By the end of the study, six months on, 78 people had recovered but 22 people were still experiencing back pain, that is to say they had developed chronic back pain. From large epidemiological studies, we know that highly disabling chronic pain incurs a significantly elevated risk of suicidal depression, terminal cancer and

fatal heart attack. So what did this study reveal about predictive factors?

Among the assessments, participants were asked to score their pain against emotional words. The 22 people who went on to develop chronic pain scored their pain significantly lower against emotional words. These results corroborate previous studies which have shown similar “attentional biases” predict poor surgical outcomes and other negative health futures. Pain, threat and stress warrant a normal emotional response in healthy people. When the emotional response appears diminished or absent from conscious awareness of the individual, it appears to precede a poor health outcome such as non-recovery.

This present study also connects very nicely with the approach of Intensive Short-Term Dynamic Psychotherapy (ISTDP) which studies have shown is able to reduce the transmission of psychological stress into the body as physical symptoms (somatisation). “It contains a direct method of assessing the somatic discharge pathways of both emotions and anxiety, thus allowing direct observation of somatisation”, says Dr Allan Abbass, leading ISTDP researcher at Dalhousie University, Canada.

Readers can find the present study on pages 45-52 in the January 2014 issue of PAIN at www.painjournalonline.com (title: “Avoidance of affective pain stimuli predicts chronicity in patients with acute low back pain”).

Placebo surgery

The University of Sydney, Australia

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On Boxing Day 2013, the New England Journal of Medicine published a study debunking yet another surgical procedure as no more than a placebo effect. The study from Finland involved 146 patients with knee pain and disability suggesting a torn meniscus (a cushioning pad of cartilage within the knee joint). They received either real knee surgery or a

“sham” surgical procedure which consisted of identical consultation, anaesthetic and arthroscopy but no actual surgery on the meniscus.

As the headline suggests, the sham procedure was found to be just as effective as the highly technical meniscus surgery.

It’s worth noting that meniscus surgery is the most common orthopaedic procedure in America with 700,000 procedures a year at a cost of $4 billion.

In February 2014, the BBC broadcast a Horizon documentary on placebo vertebroplasty for spinal fractures.

Vertebroplasty is a surgical procedure in which medical-grade cement is injected through the skin into the site of a vertebral compression fracture in the back with the aim of relieving back pain. The documentary featured the work of Dr David Kallmes, a radiologist at the prestigious Mayo Clinic in America.

Dr Kallmes has 15 years of performing vertebroplasty and in that time he observed that even when the surgery was a disaster – for example, when cement was injected into the wrong vertebrae by accident – patients’ pain and disability still improved.

Such observations lead to a formal placebo controlled clinical trial which Dr Kallmes published in 2009 in the New England Journal of Medicine. The study revealed that the sham vertebroplasty procedure, whereby the patient was convinced they were having real surgery, resulted in improvements in pain and disability that were indistinguishable from those of real surgery.

Unfortunately, despite debunking the use of vertebroplasty for spinal compression fractures five years ago, Dr Kallmes is still routinely performing the surgical procedure because there is no ethical framework outside of research for conducting placebo surgery. No new drug would ever be licensed without completing placebo-controlled trials. Sham surgery studies like these underscore the need

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research

for surgical procedures to be validated by the same placebo-controlled standards.

One wonders which other common orthopaedic and spinal surgeries are little more than risky placebos and at what cost.

Osteoarthritis and the brain

We have known for some time that chronic back pain, fibromyalgia and irritable bowel syndrome are “functional somatic” or “psychophysiologic” disorders, which are predicted by characteristic personality structures, associated with altered brain structure/function, and which respond curatively to psychophysiological therapy (see page 8). However, new research from Manchester University has now revealed insights into the relationship between pain and the brain in osteoarthritis (“When the brain expects pain”; published February 2014 in the European Journal of Neuroscience).

Professor Anthony Jones, who led the research, said: “The extent of pain experienced by sufferers of arthritis has always been thought to result from the direct consequences of joint destruction.

However, the extent of pain is often poorly related to the amount of damage and can spread to nearby regions of the body where there is no evidence of arthritic disease. We wanted to look at what might be causing this.

“Currently, it is not understood why patients with arthritis have such variability in how much pain they experience but, in spite of this, we continue to spend large sums of money using potentially damaging anti-inflammatory drugs.”

By measuring brain activity during experimental pain (laser pulses to the skin), they revealed abnormalities common to both osteoarthritis and fibromyalgia patients, compared to healthy people.

While patients were anticipating the painful laser pulse, a part of their brain called the

insula cortex was activated to a degree that matched the severity of their illness (osteoarthritis or fibromyalgia). Increased activity in the insula cortex is associated with anxiety disorders and emotional dysregulation.

Moreover, these patients also had reduced activity in the dorsolateral prefrontal cortex during pain anticipation, and this has been linked to emotional repression and maladaptive coping.

Professor Wael El-Deredy, who coauthored the study, added: “Our previous work has shown that brain responses to pain expectation can be altered by relatively short and inexpensive mindfulness-based talking therapies in patients with different types of chronic pain.”

Professor Alan Silman, medical director of Arthritis Research UK, which funded the research, said: “Focusing research on targeting abnormal brain mechanisms, rather than more conventional approaches looking at joint damage, could be a major step forward that could reduce people’s dependency on anti-inflammatories and painkillers.”

Discussion

The cost of researching a new drug is a staggering $5 billion and this must be recouped through sales, so it’s no wonder that global drug expenditure now stands at $1 trillion a year. When we think of medical research, we often think of drug companies testing the latest drug, but the true impact of most new drugs is negligible.

Here, we have three examples of new research with the potential to radically alter the course of pain medicine. What makes them so powerful is that instead of providing incremental improvements on existing medicine, they turn existing medicine on its head. At best, this kind of work serves to catalyse the evolution of medicine beyond current limits. At worst, it is ignored and never allowed to impact medical practice.

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8 TALKBACK INTERVIEW

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TALKBACK TALKBACKINTERVIEW RESEARCH 9

Your back pain treatment probably won’t work... if you keep smoking A recent study involving more than 5,000 back pain patients has shown that back pain treatments tend to fail if you continue smoking.

Dr Glenn Rechtine and colleagues at New York’s University of Rochester looked at both surgical and non-surgical treatment outcomes in both smokers and non-smokers.

While non-smokers were able to improve with treatment, those who continued to smoke during treatment saw no clinically significant improvement in their pain.

However, smokers who quit during treatment were able to achieve successful treatment outcomes.

The researchers concluded: “This study supports the need for smoking cessation programmes for patients with a painful spinal disorder.”

REFERENCE Title: Smoking Cessation Related to Improved Patient-Reported Pain Scores Following Spinal Care Authors: Behrend C, Prasarn M, Coyne E, Horodyski M, Wright J, Rechtine GR. Journal: Journal of Bone and Joint Surgery, 94(23):2161-6.

Publication Date: 5th December 2012 Online record: www.pubmed.gov/23095839

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10 TALKBACK FEATURE

The ‘godfather’ of pain recovery He is best known for his controversial curative approach to chronic pain, which he dispensed through his decades of medical practice, best-selling books and legacy of training and inspiration to a growing number of doctors and therapists who now carry the torch. We take a look at Dr John Sarno…

I

BIOGRAPHY John E. Sarno MD is a retired medical doctor and former Professor of Rehabilitation Medicine at the New York School of Medicine.

Born in 1923, he graduated in medicine at Columbia University in 1950. In 1965, he became Director of outpatient services at the Rusk Institute of Rehabilitation Medicine in New York and opened a private medical practice.

After nearly five decades in private practice, he retired in April 2012 aged 88.

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nitially, during the 1960s and 1970s, Doctor Sarno prescribed conventional treatments to the many chronic back pain patients he saw at the Rusk Institute. But he became increasingly frustrated and disillusioned with the disappointing and inconsistent results afforded by traditional approaches to pain. Relief was only temporary, and he began to question the conventional understanding of pain altogether.

He soon realised that most back pain bore no relation to any physical damage or dysfunction at the site of the pain, and noticed characteristic personality traits in his patients. Most tended to be perfectionists, conscientious but compulsive and critical – a common sign of unconscious anger. His observations led him to consider whether unconscious emotional burden might be the underlying cause of persistent pain syndromes such as chronic back pain and fibromyalgia.

A psychological cause for physical pain is quite at odds with conventional thinking, but the most compelling support for Dr Sarno’s theory of pain comes from the success he achieved with patients thereafter, curing an estimated 90% of more than 11,000 patients. Notable patients included radio personality, Howard Stern and actress, Anne Bancroft, as well as US Senator Tom Harkin who recovered after following one of Dr Sarno’s books. Howard Stern dedicated his own book to Dr Sarno and stated: “My life was filled with excruciating back and shoulder pain until I applied Dr Sarno’s principles and in a matter of weeks my back pain disappeared. I never suffered a single symptom again… I owe Dr Sarno my life.”

At the core of his revolutionary approach was helping patients to realise that the source of their pain was their own mind, rather than any physical damage or dysfunction. He said: “To get over this disorder, the patient has to focus exclusively on the psychological factors involved, which are very straightforward: their own personality traits, their

tendencies to push themselves to be perfect, to be good.” Once people became truly aware that unconscious anger was the actual cause, and not just an influence, their pain disappeared.

And he encouraged his patients to review all that they had learned with him if ever they experienced twinges in future.

Dr Sarno trained many doctors and therapists in his curative approach to pain and inspired many more through his books. Many of these went on to develop their own pain recovery programmes with similar and growing success, and some also train healthcare professionals to incorporate the curative principles into their own work. These include the Psychophysiologic Disorders Association in America (www.ppdassociation.org) and the Stress Illness Practitioners Association in the UK (www.sirpauk.com).

There is also an increasing awareness of the need to publish case studies of chronic pain recovery in peer-reviewed medical journals.

Dr Howard Schubiner of the PPD Association is among those who have already published their research, which includes a paper entitled “Recovery from Chronic Musculoskeletal Pain with Psychodynamic Consultation and Brief Intervention: A Report of Three Illustrative Cases”. The paper focuses on the cure of three cases: a 65-year-old who had suffered chronic lower back pain for nine years and who was pain free at the 11-month follow-up; a 47-year-old with post-surgical back pain for four years who was pain free at the three-year follow-up; and a 52-year-old with fibromyalgia for 14 years who was pain free at the six-month follow-up.

A graduate of the SIRPA training, Mags Clark Smith, recently presented two cases of cure at the Irish Pain Society’s annual scientific conference (see page 8).

Unfortunately, despite overwhelming evidence to the contrary, many doctors still attribute back pain to normal structural changes. Research

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shows that scan results correlate very poorly with symptoms. Many people with severe back pain have a normal looking spine, while many people with no pain have normal signs of wear and tear such as slipped discs. It comes as no surprise that treating pain as merely physical does not result in recovery. The fundamental premise of pain management is that your pain is incurable but you can learn to live with it. However, evidence from this growing volume of cases makes it quite clear that recovery from “chronic”, “persistent” or “recurrent” pain syndromes is entirely possible through deliberate intervention.

Dr Sarno coined the diagnosis “Tension Myositis Syndrome” (TMS) to describe his patients’ emotionally-driven physical symptoms.

In mainstream clinical research terminology, symptoms such as persistent and non-specific back pain fall into the class known as “functional somatic syndromes” which also includes chronic pain in other parts of the body, fibromyalgia, chronic fatigue, irritable bowel, chronic whiplash, repetitive strain and many other common diagnoses. In fact, a 2001 study conducted at King’s College London showed that more than half of clinical diagnoses are indeed “medically unexplained”.

While these conditions all appear quite different on the surface, what functional somatic syndromes have in common is that: (1) they cannot be explained by any reasonable or verifiable physical cause; (2) they can be predicted by detectable

BackCare Professional member and founder of SIRPA, Georgie Oldfield, training with Dr Sarno in 2007

psychological factors such as personality traits and emotional dysregulation; (3) they are accompanied by significantly higher rates of other functional somatic symptoms; and (4) they can be cured by psychoeducational intervention of the order that Dr Sarno administered.

Every year, 8% of the UK population develop chronic pain – that’s 14,000 a day – and yet the evidenced relationship between physical pain and the unconscious mind remains largely unknown to the general public. Unlike the latest drug, there is no multimillion dollar budget to promote Dr Sarno’s breakthrough. But there is a more insidious barrier to cure and it permeates our society’s outlook on health. For many, the mind is still a taboo. Some fear that in accepting the TMS diagnosis they must incur a “fall from grace”. It may be deemed brave or heroic to be having surgery, but the prospect of psychological therapy is deeply shameful to many. There is a fear they will be branded as weak or malingering, that it is somehow “all in their head”.

Chronic and nonspecific pain is, of course, very real and no more “imaginary” than blushing for any other emotionally-driven physiological response. But until this can be accepted, pain management remains the glass ceiling.

Nonetheless, evolution is a natural and inevitable process and the human species has overcome many similar “reality barriers” over the course of its history. The good news is that the reality of chronic pain recovery is already firmly established, albeit in discrete pockets of activity. As writer William Gibson once noted: “The future is already here — it’s just not very evenly distributed”.

Doctor Sarno at the US Senate Committee on Health chaired by ex-chronic pain sufferer Senator Harkin in 2012

The New York Times best seller, Healing Back Pain, published in 1991

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12 TALKBACK EDUCATION

Prevention is better than cure PART 5

Insomnia “Prevention is better than cure”, or so the old adage goes. And it’s perhaps not surprising to find that, when it comes to preventing illness and promoting health, a lot of what’s important for healthy backs is also beneficial for our overall health. Sleep is a vital life-sustaining “nutrient”, third in importance only to air and water, and its long-term disturbance is associated with serious health consequences. In this episode, we’ll be exploring how insomnia is related to physical and psychological health and what you can do about it.

What is insomnia?

The affliction of sleeplessness is commonly known as insomnia. A more robust and academic definition is that insomnia is a sleeprelated disorder that involves difficulty initiating sleep or difficulty maintaining sleep or nonrefreshing sleep and which is associated with daytime consequences, despite adequate opportunity and circumstances1.

While many surveys report the prevalence of adult insomnia at around 30%, this drops to around 10% when you include perceived daytime impairment or distress in the diagnostic criteria2,3.

These distinctions may be important if we want to be sure we’re discussing the same thing.

Overall, it is worth noting that around a third of adults report some degree of insomnia and one in 10 report adverse impact on their daily life.

Back pain and sleep

Persistent back pain and persistent insomnia commonly occur together. One study comparing 70 chronic back pain patients with 70 genderand age-matched controls found insomnia was 18 times more common in people with chronic back pain: 53% versus only 3% respectively4. On average, around 50-70% of chronic pain patients have clinical insomnia,4-8 compared with up to 30% among general population samples2,3.

Evidence suggests that pain and sleep have a bidirectional or cyclic relationship, whereby pain disturbs sleep and sleep disturbance worsens

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pain9-14, though this does not necessarily mean that either one actually causes the other.

Overall, it is worth noting that persistent pain and insomnia frequently co-occur.

Measuring insomnia

In order to understand the factors that influence sleep better, researchers have developed a number of self-report questionnaires to measure insomnia. One such measure is the Insomnia Severity Index (ISI) which has been used in hundreds of clinical studies since it was developed in 2001. The ISI measure asks the

More than half of back pain sufferers also suffer from insomnia

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participant to score their insomnia on a five-point scale against seven questions or statements. This kind of questionnaire helps to assess the qualities and severity of insomnia.

Many of the studies referenced in this current article used the ISI assessment to measure insomnia. The reader can use the questionnaire provided below to assess their own insomnia and relate it to the research evidence discussed in this article.

Insomnia and emotions

Pain and sleep disturbance do frequently co-occur, but the actual severity of pain and insomnia only weakly correlate4,15. It is reasonable to interpret this as suggesting that chronic pain and insomnia do not cause one another, but rather that they share a common cause.

While insomnia severity only weakly correlates to chronic back pain intensity, it strongly correlates to emotionally laden pain, “affective pain”4, as measured by asking the patient to score their pain against the emotional descriptors, specifically: “exhausting”, “sickening”, “fearful” and “punishing”16. Furthermore, a recent prospective study of 100 acute lower back pain sufferers found that avoidance (“negative attentional bias”) of emotional pain descriptors predicted who would develop chronic pain17.

So we have evidence that links insomnia and chronic pain through detectable alterations in emotional processing. It is noteworthy that a similar bias away from negative and threatening emotions also predicts poor surgical outcomes18-20.

Personality traits

Several studies have investigated the link between personality traits and insomnia.

In 1983, researchers at Pennsylvania State College of Medicine published a study of personality structure in 428 chronic insomniacs. They assessed personality using one of the most widely used and best researched tests of adult personality, the Minnesota Multiphasic Personality Inventory (MMPI – see footnote on page 20).

The study revealed that the personality patterns of chronic insomniacs were remarkably similar and consistently characterised by neurotic depression, rumination, chronic anxiety, inhibition of emotions and an inability to discharge anger outwardly21.

Personality test predicted insomnia seven years later Almost three decades later, in 2012, another team of researchers at Pennsylvania State College of Medicine published a study looking at the factors that predict chronic insomnia. They recruited 1,246 individuals without chronic insomnia from the general population and took baseline measurements, including medical, psychiatric and sleep histories, as well as personality (assessed by MMPI-2).

These individuals were followed up after seven-and-a-half years, in which time 133 (11%) had developed chronic insomnia.

These incident chronic insomniacs had “a pre-morbid psychological profile of higher neuroticism and excessive

rumination with a tendency to suppress negative emotional content (internalization) and a decreased ability to cope, as revealed by higher scores on MMPI-2 scales of depression, social introversion, and repression, and lower scores on the ego strength scale”22.

How does this relate to pain? In 2005, researchers from Duke University Medical Centre in North Carolina published a study in which 2,332 individuals were given the MMPI assessment as college students in 1967 and then followed up 30 years later in 1997. Those who reported experiencing one or more chronic pain syndromes at the follow up had scored significantly higher on the initial MMPI assessment23. The evidence from these substantial studies quite clearly demonstrates that chronic pain and chronic insomnia are preceded by the formation of characteristic personality structures.

Childhood trauma

Our genetics interact with our physical and psychological environment to determine our observable and detectable characteristics, including personality. Thus, when we want to trace the relationship between personality, pain and insomnia to a deeper level, we may consider childhood events, particularly “formative trauma”. Indeed, there is a significant correlation between childhood trauma (emotional abuse, physical abuse and witnessing violence) and the number of pain and psychophysiological disorders in adulthood24.

A Swiss study of 59 patients with primary insomnia (i.e. insomnia without medical cause) found that 46% reported moderate

Rate the last two weeks of your sleep problem from 0-4 using the following questions, A-G: 0 = “None”

1 = “Mild(ly)”

2 = “Moderate(ly)”

3 = “Severe(ly)”

4 = “Very severe(ly)”

A) Difficulty falling sleep B) Difficulty staying asleep C) Problem waking up too early D) How DISSATISFIED are you with your CURRENT sleep pattern?

E) How NOTICEABLE to others do you think your sleep problem is in terms of impairing your quality of life?

F) How WORRIED/DISTRESSED are you about your current sleep problem?

G) To what extent do you consider your sleep problem to INTERFERE with your daily functioning (e.g. daytime fatigue, mood, ability to function at work/daily chores, concentration, memory, mood, etc.) CURRENTLY? The scores for all seven items are then added to give the final score: 0–7 = No clinically significant insomnia 8–14 = Sub-threshold insomnia 15–21 = Clinical insomnia (moderate severity) 22–28 = Clinical insomnia (severe) continued on p14

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14 TALKBACK EDUCATION

Prevention is better than cure: insomnia fe se in li PurPo

from p13

Formative trauma is significantly higher amongst those who develop persistent insomnia and pain to severe adverse childhood events, as measured by the “Childhood Trauma Questionnaire” (CTQ), and that the severity of sleep disturbance correlated to the severity of childhood trauma25.

Likewise, a Norwegian study which analysed the medical histories of 100 chronic pain patients found that 44% had previously reported serious childhood trauma long before the development of physical pain26; and an American study of 117 chronic non-cancer pain patients found that 62% reported at least one of five categories of childhood trauma (physical abuse, emotional abuse, sexual abuse, physical neglect and witnessing violence)27.

These figures are around 2-3 times higher than the prevalence of childhood trauma reported by healthy individuals (24%)28. As a side note, studies have shown that patients of several chronic medical conditions have significantly higher CTQ scores than matched controls from the general population – 331 rheumatoid arthritis patients29; 153 fibromyalgia patients 30; 234 multiple sclerosis patients31.

Emotions and the body

How we feel in relation to current pain, stress, threat and life itself can be understood as a consequence of personality, which in turn can be understood as a consequence of formative life experiences. We’ve covered evidence that relates all three of these – emotional processing, personality traits and childhood events – to persistent or recurrent insomnia and back pain. But how can emotions, personality and your childhood predispose you to developing physical illnesses?

The answer lies in the “hypothalamicpituitary-adrenal (HPA) axis”, an anatomical assembly comprising the amygdala (a part of the brain involved in processing memories and emotional reactions), the hypothalamus (a part of brain that connects to the “endocrine” or glandular system), the

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pituitary gland (an endocrine gland at the base of the brain) and the adrenal glands (a pair of endocrine glands located at the top of the kidneys). Endocrine glands such as the pituitary and adrenals release hormones into the bloodstream, providing the physiological means through which emotions regulate every tissue and organ in the body.

Adults who have experienced childhood trauma show significant and sustained changes in the functioning of the HPA axis32-34. The HPA axis is responsible for processing stress and for the transmission of stress into the body in the form of the normal “fight-flight-freeze” response as well as the maladaptive response that underlies psychophysiologic disorders such as chronic insomnia and chronic pain.

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Insomnia and health

In part 3 of this series (“Rethinking Chronic Pain” in TalkBack, summer 2013), we discussed the health implications of chronic pain in some depth. Chronic insomnia is also associated with seriously adverse health futures. The most consistent impact of chronic insomnia is the high risk of depression35.

A six-year study of 23,000 cancer-free male insomniacs found a 32% increased risk of death from cardiovascular disease in those reporting non-refreshing sleep most of the time, and a 55% increased risk in those reporting difficulty falling asleep most of the time36. In women, sleep disturbance through night shift working, while not insomnia per se, significantly increases the risk of breast and ovarian cancers37,38.

So, if we know that insomnia is associated with serious ill health, and we know it is strongly associated with emotional state, personality trait and formative trauma, what can be done for the current insomniac or indeed for the apparently predestined future insomniac? To address this question, we can work up through the stages of health engagement as presented in part 2 of this series (“What is Health?” in TalkBack, spring 2013; diagram inset).

Spiral graphic.indd 24

Persistent insomnia increases risk of depression and death

Suppressing insomnia

The palliative approach to medicine typically involves using drugs to suppress symptoms. The premise here would be that insomnia is an undesirable symptom and we can take a sedative to induce sleep and provide an experience of relative health. This can be productive in the short-term, but drug therapy for chronic insomnia and chronic pain is a very poor long-term option, not only because of side effects, but because it can institutionalise the individual into passive and dependent patienthood. Once medications are removed, the suppressed symptoms may return in full and may also be accompanied by a prolonged withdrawal syndrome.

A number of classical folk remedies for sleeplessness such as valerian, hops and passion flower have become popular overthe-counter sleep aids. Some preparations appear ineffective 39, though combinations and appropriately dosed preparations have been shown to be effective for the short-term alleviation of primary insomnia40.

Supplementing with minerals, such as magnesium and zinc, or sleep-related biochemicals, such as melatonin, also tend to appeal to “natural”-minded insomniacs and have some supporting evidence in placebo-controlled trials41,42.

Modern synthetic drugs are, of course, the mainstay of prescription and over-the-

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counter medicines. Sedative antihistamines such as diphenhydramine (e.g. ‘Benedryl’) are a common over-the-counter option.

On prescription, barbiturates are a powerful class of central nervous system depressant and have been used for everything from sedation to anaesthesia to euthanasia, although are now largely replaced by benzodiazepine drugs such as diazepam (e.g. ‘Valium’) and alprazolam (e.g. ‘Xanax’). Benzodiazepines carry reduced risk of fatal overdose, but still carry substantial risk of dependence, abuse, impairment of memory and thinking, social and sexual dysfunction and loss of interest in life. Certain anti-depressant drugs have sedative effects and may be deemed appropriate where anxiety or depression occurs alongside insomnia – these include amitriptyline and mirtazepine.

Next generation insomnia drugs are very different from traditional sedatives.

The drug, ramelteon (“Rozerem”) works by mimicking melatonin, the body’s natural sleep-regulating hormone. It doesn’t cause any of the usual sedative side effects, although it does increase cancers43.

Overall, regardless of whether the drug of choice is natural or synthetic, over-thecounter or prescription, powerful or mild, or

even next generation, these agents all fall into the palliative category which operates on the basis that health is merely the absence of symptoms and which seeks to suppress the complaint rather than seek its ultimate resolution. In fact, this sequence from gentle herbal to powerful synthetic to next generation is a typical illustration of the “more-newer-better” approach to progress, which fails to grasp that moving beyond existing limitations requires a fundamental rethinking of how we define health, illness and medicine. Having said that, we must remain sensitive to the fact that many people will not engage health in a more sustainable manner, so there remains a need for safe and effective drugs.

Managing sleep hygiene

Sleep hygiene is defined as all behavioural and environmental factors that precede and may influence sleep44. According to the International Classification of Sleep Disorders, insomniacs often show little insight into the disruptive effects of poor sleep hygiene which are usually obvious to others45. Chronic insomniacs do appear to engage in specific poor sleep hygiene practices, such as smoking and drinking, before bed46. However, these behaviours

may constitute attempted self-medication and self-correction.

It’s important to understand that poor sleep hygiene may disrupt sleep and sleep disruption may precipitate the behaviours of poor sleep hygiene. As with chronic pain and chronic insomnia, it’s not that poor sleep hygiene completely accounts for insomnia, or vice versa, but rather that our thought processes, emotional processes and behavioural processes emerge in relation to one another – this is to say, the chronic insomniac tends to think, feel and act like a chronic insomniac.

If your inadequate sleep hygiene is part of your maladaptive coping behaviours, then fixing your sleep hygiene may not fix your insomnia, or you may find that it’s almost impossible for you to maintain consistently good sleep hygiene.

Nonetheless, some basic and typical sleep hygiene recommendations would include: allow sufficient time for sleep – quite simply, if you stay up until 2am and set your alarm for 6am you will never get the recommended seven to nine hours of sleep a night; heavy meals, alcohol, caffeine and stimulating or sedating drugs or medications should all be avoided before bedtime if possible; the sleep environment should be very dark (ideally pitch black),

17/03/2014 13:04

continued on p16

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Prevention is better than cure: insomnia from p15 quiet, comfortable and cool; using your smartphone, tablet or laptop in bed should be avoided; exercising earlier in the day can promote restful sleep at night, but intense exercise immediately before bed is not recommended; schedule wind-down time before bed; reserve the bedroom for sleep and sex only; avoid bright lights for two to three hours before bed (or wear blue-blocker glasses for this period).

In contrast to suppressing insomnia, managing sleep hygiene seeks to control the factors that lead up to the night’s sleep and instil the behavioural habits associated with restful sleep. This category may also include “state-change” or relaxation activities such as using a hot bath or cold shower, or audio technologies such as sleep hypnosis or brainwave entrainment to bring the mind or brain or body to a state conducive to restful sleep. These activities are arguably not sedative per se, and may be too subtle for some but can be used in the context of scheduled wind-down time before bed.

Fixing thoughts and behaviours

Sleep hygiene may also be addressed as part of a cognitive behavioural therapy (CBT) programme. CBT uses explicit and systematic procedures to identify and change maladaptive and dysfunctional thoughts, emotions and behaviours which have become, or are contributing to, definable clinical disorders. It has proven effect in a variety of mood, personality and behavioural conditions and has also been successfully applied to insomnia (CBT-I). The CBT-I intervention incorporates five distinct therapies: stimulus control; sleep restriction; relaxation training; cognitive therapy; and sleep hygiene education47. Stimulus control therapy is a set of simple instructions designed to re-associate the bed and bedroom, specifically: go to bed only when sleepy; get out of bed when unable to sleep; use the bed/bedroom for sleep only, no reading or television; get up at the same time every day; and no napping. Sleep restriction therapy is designed to reduce the amount of time spent lying awake in bed, so if the patient reports sleeping for six of the eight hours spent in bed, their time in bed would initially be restricted to six hours.

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Relaxation training may involve guided visualisation, meditation, progressive muscle relaxation or other evidence-based techniques to reduce tension in the body and mind which may interfere with sleep.

Cognitive therapy seeks to challenge and change misconceptions, faulty beliefs and obsessive behaviours in relation to sleep (e.g. clock watching and “trying” to fall asleep). Sleep hygiene education teaches the insomniac about the aforementioned behavioural and environmental factors that may interfere with sleep (e.g. exercise, food, caffeine, alcohol, temperature and light).

In 2004, a study of nine psychophysiologic insomniacs showed significant improvements in a number of subjective and objective measures of sleep after eight weeks of CBT-I treatment. The average Insomnia Severity Index (ISI; see pages 12 and 13) score dropped from 16 points (“moderate clinical insomnia”) to six points (“no clinically significant insomnia”); the average time taken to fall asleep (“sleep latency”) dropped from 28 minutes to under seven minutes; and average total sleep per night increased by 90 minutes48.

In 2006, a Norwegian clinical trial compared CBT-I, a sedative (zopiclone, 7.5mg) and placebo pills for six weeks in 46 older adults (average age: 61 years) with primary insomnia. The effects of the sedative were similar to those of the placebo pill, whereas those receiving CBT-I spent significantly more time in deep sleep and less time lying awake in bed49. More recently, hybrid CBT, specifically designed for insomnia in chronic pain patients, has been shown to improve insomnia, disability, depression and fatigue significantly over and above improvements from separate CBT programmes for pain or insomnia50,51.

However, the level of pain remained unchanged.

Medication versus meditation

Mindfulness-based stress reduction (MBSR) is a behavioural medicine programme that was developed in 1979 at the University of Massachusetts Medical School. It has been researched in hundreds of clinical trials over the last 15 years and involves meditation techniques taught through eight weekly sessions with a day

retreat in the final week and instructions for home practice.

A small 2011 study compared MBSR with drug therapy for primary insomnia52.

Over the five-month trial, 18 patients received MBSR (eight-week course followed by three-month home practice expectation) and nine patients received a nightly sedative (eszopiclone, 3mg).

Sleep diaries and several assessments, including the ISI, were used to record measurements before and after. After eight weeks, more than a third of patients in both the meditation and drug groups had “recovered” from their insomnia as defined by a normal score across six reliable assessments and measures. By five months, almost half in each group had recovered, showing that MBSR is as effective for insomnia as a prescription drug, while also providing the many other health and wellbeing benefits that have been evidenced for mindfulness meditation.

In 2014, another study compared MBSR with CBT-I for insomnia in cancer patients53. CBT-I produced rapid improvement in insomnia, which remained stable at the five-month follow up. The benefits of MBSR (in 27 patients) were less immediate but were comparable to the benefits of CBT-I (in 37 patients) by the end of the trial. Anxiety and mood improved similarly in both groups. The reduction in dysfunctional beliefs about sleep was more pronounced in those who received CBT-I, presumably because it contains specific therapy targeting such beliefs.

MBSR has not proven consistently effective for reducing back pain per se, but may reduce suffering despite pain by promoting acceptance54. Since specific beliefs are strongly associated with pain and clinical prognosis in general, and given that meditation does not specifically target the content of beliefs, we may wonder whether the impact of MBSR for pain is more highly dependent upon the patient’s expectations (we know that expectation can double or entirely negate the effect of pain killers)55.

Recovering from insomnia

As we have seen, chronic insomniacs can regain clinically defined “normal” sleep,

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without drugs and as assessed by a variety of reliable measures, by following either the CBT-I or MBSR programme. Some studies use the term “recovery” to describe this positive change. You might even say they have been “cured” of insomnia. However, there remains one loose end from the perspective of curative medicine, namely the preceding psychological factors shown to predict and typify insomnia.

As discussed, several large studies have shown significant and predictive associations between insomnia and preceding traumatic experiences, personality formation, and emotional dysregulation. These same psychological factors also appear to precede, and be associated with, the development of chronic pain and several other physical illnesses.

From the curative perspective, these psychological factors are causal and recovery occurs to the degree that the cause can be addressed. Nonetheless, there is little in the way of published academic research to demonstrate the cure of insomnia in this manner.

Interpersonal therapy (IPT), which is

normally used to treat depression and which focuses on relationships and conflict, has been shown to be an effective treatment for primary insomnia (i.e. insomnia that is not caused by depression or other clinical conditions). A small study in 1996 compared IPT with a progressive relaxation technique in 25 patients over 12 sessions. IPT significantly increased the time spent asleep in bed and reduced time taken to fall asleep, while the relaxation technique was ineffective56.

The important concept here is that the underlying cause, for example a traumatic event that contributes symptomatically to current relationships, may bear no superficial relationship with the symptom/ syndrome, for example insomnia or chronic pain. And yet, on the basis of the curative model of medicine, by addressing the underlying cause, the seemingly unrelated symptoms are cured. Formative trauma (i.e. experiences perceived as negative which have a deeply lasting effect by influencing the ongoing formation and maturation of personality structure) set up a personality structure which predisposes the individual to generate psychological stress and to

express that stress in the form of physical symptoms/syndromes.

So what is the difference between a return to clinically normal sleep through MBSR or CBT-I and this notion of recovery that relates to addressing an underlying psychological cause? People with anxiety or depression are two to three times as likely to have multiple somatic symptoms such as back pain, heartburn, nausea, constipation57. Nearly 90% of people with chronic pain have pain in multiples sites58.

“Medically unexplained” or “functional somatic” symptoms, such as chronic pain, irritable bowel, fibromyalgia, frequently occur in the same individuals alongside primary insomnia, anxiety and depression.

To be clear, CBT-I has been shown to restore clinically normal sleep in chronic insomniacs and has been shown to improve chronic pain and fibromyalgia, but what is the health future of an individual for whom the psychological factors strongly associated with so many illnesses remains intact? Ultimately, if such symptoms represent functional expressions of a common underlying cause, then “pinching off” a symptom at

continued on p18

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Prevention is better than cure: insomnia from p17 the surface through a targeted intervention may certainly give the appearance of recovery from that symptom while leaving the cause intact and free to animate other symptoms – as Sir Professor Simon Wessely asserts: “There is only one functional somatic syndrome”59.

An analogy of picking the fruit versus uprooting the tree is apt. This does not mean that chronic pain, chronic insomnia, chronic fatigue, fibromyalgia and irritable bowel are “all the same”. On the surface, each condition warrants its own diagnostic label as each certainly looks and feels different and involves different structures of the body. However, the curative model of medicine focuses beneath this surface of appearances to the factors found to unite these conditions, with the thesis that cure lies in reconciling the underlying cause.

These uniting factors tend to include life event-driven emotional dysregulation reflected in personality, dysregulation of the physiological systems that connect the brain and body (e.g. the HPA axis), and alterations in brain structure and function.

(This concept of cure is illustrated in the two case studies on page 8.)

Preventing disease versus promoting health Curing illness is a major milestone in the evolution of medicine, but it is not the end of the road and there are further reaches of health engagement which can develop.

Beyond curative medicine lie ways of being and living that do not sustain illness.

Healthy living may be thought of as preventative, but “disease prevention” tends to focus on mitigating known risk factors for specific clinical diagnoses, such as anti-smoking campaigns to prevent lung cancer. Each successive stage of development builds upon the former, so aiming to prevent apparently incurable diseases could not rightly be designated as “beyond cure”. By contrast, health promotion focuses on factors that generate health, rather than factors that generate disease.

The World Health Organisation defines health as “a state of complete physical, mental and social wellbeing and not merely the absence of disease or infirmity”, and defines health promotion as “the process of enabling people to increase control

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over their health and its determinants, and thereby improve their health”.

Curative medicine marks the final stage of health engagement to focus on illness and is succeeded by health promotion which seeks to generate health. At this altitude of health engagement, activities do not look like medicine as it has formerly been known. For the insomniac audience, health promotion may not appear to address their insomnia – there are neither anti-insomnia drugs nor remedial insomnia therapies. It’s certainly a very different way of thinking about health, because we so often think of health in the context of its opposite (disease), and necessitates different ways of measuring health that don’t focus on symptoms or the clinical thresholds that define normal functioning.

One illustrative example is the “sense of coherence” (SOC) construct which was developed by medical sociologist, Professor Aaron Antonovsky, and which he measured using a 29-item scale encompassing three dimensions: 1) Comprehensibility (cognitive) – the belief that your life makes sense and is understandable.

2) Manageability (behavioural) – the belief that you have the ability, or support and resources, to control and take care of things in your life.

3) Meaningfulness (motivational) – the belief that your life is interesting and satisfying and that the demands of life are challenges worthy of engagement.

The SOC scale has been used in several hundred research studies to date and higher SOC has been found to predict or be associated with: restful sleep among 511 Japanese older adults60; uncomplicated childbirth among 145 pregnant Israeli women61; remaining a non-smoker among 2,119 South African adolescents62; absence of dental caries among 994 Finnish adults63; non-smoker status, being more physically active and

Feeling that your life makes sense and is manageable and meaningful predicts more restful sleep

eating more fruit and vegetables among 18,287 residents of Norfolk, UK64; and lower risk of all-cause death among 12,024 Dutch adults65.

What about the body? Yes, it is certainly worth mentioning exercise and physical training, which has profound effects upon the mind and body. Both aerobic (e.g. running) and resistance (e.g. lifting weights) exercise have been shown to improve sleep66. A small study of healthy elders (average age 78) showed that lifting weights thrice weekly for 12 weeks significantly increased physical strength and sleep quality67 . What’s interesting with this study is that the elderly participants were already assessed clinically as being “good sleepers” and yet their sleep still significantly improved, which ties in nicely with the notion of positive health promotion. Furthermore, we have clinical evidence that sense of coherence can be increased through deliberate intervention in schoolchildren68, college students69 and adults70. But what can be done for tonight’s insomniac?

Solutions for tonight’s insomniac

We have travelled some considerable way from the discussion of sedatives and supplements. Each new level of health engagement promises an increasingly optimistic outlook on an increasingly complete and sustainable appraisal of health. However, while it may be relatively effortless to obtain and use sleep remedies (or alcohol), engaging with psychological and behavioural interventions, as are often involved in the approaches beyond drug therapy, represents a deeper and usually longer term commitment. So what of the insomniac reader who has come to realise new ways forward but dreads the coming night? A recipe follows.

Evoking positive emotions for social connections triggers a “relaxation response” by activating your “parasympathetic nervous system”71.

Sit down with a pen and paper. Make a list of between five and 10 people with whom you share a positive relationship.

Now write down the three qualities you most value in them and the three qualities you feel they most value in you. Finally, activate the psychology of accountability continued on p20

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Don’t confuse discomfort with harm – yes, a proper cold shower should feel shocking

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20 TALKBACK EDUCATION

Prevention is better than cure: insomnia from p19 and commitment to social norms72 by making contact with one of these people right now to tell them why you have chosen to engage in this interesting sequence of health-related activities.

Cold water exposure also increases parasympathetic activation73,74. Take an actual cold shower, exposing your head and entire body to cold water (around 12°C) until it no longer feels shockingly cold, which typically occurs within five minutes. Don’t confuse discomfort with harm – yes, a proper cold shower should feel shocking. If this is too much to bear, immerse only your face in cold water for a full five minutes75,76. If this is still too much to bear, you can use deep breathing

with prolonged expiration to increase parasympathetic activation77,78. Inflate your lungs completely and quickly within one to two seconds. Then exhale slowly but forcefully through pursed lips for between four and seven seconds. Repeat this cycle until you can feel the relaxation response, which typically occurs within two minutes.

Engage fully with all prescribed activities – do not skip the cold shower unless you have a medical reason. Go to bed when tired, rather than early, and harness the power of ‘paradoxical intention’ by remaining passively awake without any effort to fall asleep, rather than trying to fall asleep. You can report your results by email to yourstory@backcare.org.uk

Footnotes

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MMPI – The Minnesota Multiphasic Personality Inventory is one of the most widely used and researched tests of adult personality. It measures multiple themes including: concern with bodily symptoms; awareness of problems and vulnerabilities; conflict, struggle, anger, respect for society’s rules; stereotypical masculine or feminine interests/behaviours; level of trust, suspiciousness, sensitivity; worry, anxiety, tension, doubts, obsessiveness; odd thinking and social alienation; level of excitability; and people orientation.

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TALKBACK l WINTER 2013/14

Why Back Pain?

There is a disease spreading across the UK, claiming 7,000 new victims every day. It increases your risk of fatal heart attack and terminal cancer. It causes structural changes to the brain and increases your risk of suicide. It’s also resistant to conventional NHS treatments.

Sounds like a horror movie, right? Actually, we’re talking about highly disabling chronic back pain, which now affects around 1-in-20 people and millions more every year.

Because back pain is so common, most people have no idea how serious it can be.

Yes, most back pain is not serious and goes away by itself just like headaches and the common cold. But for hundreds of millions of people worldwide, the pain becomes chronic and never goes away. For many it is torture, all day, every day, forever.

Not only can back pain destroy lives, but it also costs huge amounts of money in NHS treatments, disability benefits and sickness absence – more than £50 million a day. In fact, the amount of money the UK spends on back pain in just one year would solve the entire water crisis in Africa where 4,000 children die each day from contaminated water. Makes you think, doesn’t it?

Why BackCare?

BackCare is the UK’s national back pain charity. Our mission is to turn the tide on back pain through our research, education and outreach initiatives. We are a unique charity and no one else is doing the same work.

Just by reading and sharing this magazine, you are helping to support our work – thank you.

Why Not Donate?

Back pain is a major global health problem. By donating to BackCare you are helping a very worthy cause. We are very grateful for all donations and people can donate their time, effort or money in many different ways – whether that’s volunteering your skills, organising a fundraiser, running the marathon or simply popping a cheque in the post.

Why not get in touch to find out how you can get involved?

Call us today on 0208 8977 5475 or email yourstory@backcare.org.uk

www.

The Charity for Back and Neck Pain

.org.uk