Letter to a friend in pain

By David Butler Pain literacy education, Physio world 02 Feb 2021

I have never liked treating relatives and friends – somehow that unquantifiable ‘magic’ goes missing. But over Christmas, a friend rang –  “I’m in agony Dave, terrible back pain, two herniated discs, leg pain… my friend says I’ll need surgery ”. There were difficulties seeing practitioners (no problems getting an MRI though!), and the virus was complicating travel.

“I’m retired,” I said. Then I felt guilty and wrote a note.  Here it is, just as I sent it.

A story of herniated discs and leg pain by Dave

Around 1934, two surgeons called Mixter and Barr (should have run a grog shop with those names) reported ruptured discs pressing on nerve during surgery and wrote up their observations in a famous medical journal, ushering in what has been called ‘the dynasty of the disc’.  Disc surgery flourished and nearly every system of physical treatment focussed on the disc. Lamborghinis were bought. Over time, studies increasingly reported that disc surgery was not helpful. There were also reports at surgery that just when they were about to chop a bit out, if the patient was moved, the herniation (ie. bulge) disappeared. Imagine the consternation in the operating theatre. Discs hardly have a nerve supply too.

In many places, the numbers undergoing back surgery are finally coming down and the current guidelines for optimal management of back pain can be now be made are based on a ton of quality research. Basically, most people get better by themselves with a bit of guidance, time and understanding.

Now dear XXXXXX, here is Dave’s 10 point plan to a beautiful back

  1. Know that discs bulge, herniate and degenerate in us all. (We all start to gently rot at the age of 15). These changes are nearly always a normal part of life. An MRI will often show them in people without pain and on the opposite side of the spine to the painful side. There is an ‘avoid the MRI unless you really need it’ movement out there.
  2. I took the artist for ‘Explain Pain’ to the anatomy lab and showed him some dissections. He loved holding brains and heads but most memorable for him was a transverse low back body slice though a disc so he could see how tough it was and all the ligaments around it. ‘That fucking thing is never going to slip or go anywhere’, he said.
  3. However, XXXXXX, we take more notice of disc changes if there has been significant trauma (eg. fall from a height, driving your Merc into a tree) and if there are signs of nerve compression. Weakness is a big one – when you can, make sure you can stand on tippy toes and also be able to stand on your heels. Bladder and bowels not working and a numb crutch means getting checked out urgently. This is rare. Constipation is quite common when you aren’t moving much and are on painkillers.
  4. Nerve irritation is possible and may be linked to some leg pain. This will pass and it’s often a good sign if sore areas at a distance from the back get better first.
  5. So what to do: rest is best for a few days, hot water bottles are nice, the back support will help, Ibuprofen too – all settles the local inflammation. Gin and vodka may help (but don’t overdo it). I heard you had a steroid injection – these can help if they find the right spot. Avoid parachuting. Some walking if you can stand up and get straight will be helpful.
  6. Tease the back movements – lie on your tummy if you can and come up onto your elbows. Try lying on your back and rolling and twisting. Do nerve wriggling – lie on your back, bend hip to 90 degrees, clasp hands behind thigh and slowly extend the knee. Do it on the non-sore side first. You can’t hurt yourself doing this. All wriggling and teasing is lovely and helps to drain any inflammation and swelling away.
  7. Know that it will get better.
  8. Pain is made by brains in beautiful bodies in wonderful worlds, not just boring backs. Just like love doesn’t come from the genitals, pain doesn’t come from the back!!!! Messages sent from the back to the brain can contribute to pain of course. People in pain have a brain lit up like a Christmas tree on fancy scanning. The input from the back is just one of these lights. There is a back pain network in your brain. There are a zillion other contributions – memories, thoughts, COVID, Christmas, the word ‘herniation’, life’s stresses and challenges. Change any of these and aches and pains can change.
  9. All pains and injuries involve the immune system. It goes a bit out of balance. Anything that balances the immune system will help. The known immune healthy behaviours are: working out ways to cope, graduated exercise, anti-inflammatory foods, laughter, sleep well, seek any interaction with nature (yes – hugging trees can help), ease up on the ciggies and booze, drugs with opioids in them can make you more sensitive over time, challenge your initial perception about how bad it was (surgery thoughts etc!) and seek knowledge about your wonderful inner workings.
  10. Come and see us when you get home, but in the meantime, always ring for free advice.

Dave xxxx

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