That Proverbial 'Bad Back'

Goldfish has already had one pop at this BBC article, but I want to pick it up on a specific point and look at it on a little more personal a basis than I would normally use for WTB.

"during that time there was a widespread belief that back pain could be long-term and could seriously incapacitate people.

Now, people are aware that if they strain a muscle they can be better in a few weeks, Professor Coggon said."

Alleluia! Praise the Lord! I'm cured!

Or maybe not. Maybe there's more to it than the 'good' Professor Coggon is letting on.

We've been seeing a lot of this in the past few months, disabling conditions deliberately undermined to outrage the Tabloidigentsia. Cystic Fibrosis - cough. Epidermylosis Bullosa - blisters. Prader-Willi Syndrome - obese. It's bad enough when they target the rarer conditions without the weight of numbers to enable the people with them to fight back, but a constant in the background statistics when people with these conditions are derided are the far larger figures for 'depression' and 'bad back', with the unspoken intimation that these are just as false. I don't really have the background to discuss clinical depression beyond being sadly aware of how badly skewed are the opinions of the vast majority in our society towards it, but 'a bad back' I have known intimately for twenty-odd years.

The first thing to notice is the labelling, always 'bad back', never 'spinal injury', because that deliberately taps into the undercurrent of belief that we are all shirkers and fakers. Most people have had some experience with back pain, some will even proclaim that they 'suffer with their back', but almost always there will be the implied 'but I cope and so should they'. Then along come tame experts like Professor Coggon, proclaiming that back pain can be cured, if you really want to be cured.

Strangely enough the hired guns always seem to be occupational health doctors, the ones whose bread and butter comes from saying what industry or government wants of them, you never seem to see a spinal surgeon or a pain management specialist up there rubbishing the reality of these disabilities.

A soft tissue spinal injury may have a good chance of healing in a few months, but for many people that healing never occurs, because it isn't simply a pulled muscle - thanks for that one, Professor Coggon! Let's really undermine the shirkers with the most trivial injury imaginable - it's a much more complex situation involving injuries to muscle, bone, nerves and discs. There's a wonderful phenomenon called 'neuroplastic remodelling' in which the spinal cord rewires itself to make pain normal, even if the original injury is gone. Then there's Chronic Pain Syndrome, which is a label for pain that continues longer than 3 months without clear physical cause. Or Facet Joint Syndrome, which is pain from damage to the facet joints at the tip of the wings of the vertebrae, Or Degenerative Disc Disease, in which the discs slowly narrow and can burst, while the vertebrae grow arthritic spurs of new bone, all of the changes constricting the space through which the nerves are meant to pass. And so on. A whole medical speciality's worth of long term conditions that won't magically go away in three months because some hired gun who specialises in 'Occupational Health' says that they should. Even 20 years on I don't really have a clear diagnosis for everything that's going on, my local rheumatology department recently told me they don't actually have anyone qualified to assess my complete set of spinal issues. And I'm far from alone in that. The absence of a definitive diagnosis even after decades of seeing specialists is not a cause for suspicion, it is a recognition of the sheer range and complexity of spinal injuries.

"If it was real it would show up on an x-ray, or an MRI" the self-proclaimed expert in the pub or the office will often claim. Unfortunately self-proclaimed is not the same as actual. I had so many x-rays in the years after I initially became disabled that I was starting to worry about glowing in the dark, never mind cumulative dosage, yet they showed nothing and my consultant was visibly stressed at his failure to isolate the cause because he could see my disability was very real. It finally took a full body bone scan with radioactive tracer to get even a hint of what was going on, and if the problem had been solely neurological, for instance through neuroplastic remodelling, then not even that would have been true. My more recent c-spine problems do show up on MRI, but it was four years from onset of C-spine problems to getting that MRI, 21 years on from first presenting with a clear spinal injury. After 22 years of spinal problems that remains the only spinal MRI I have had, and the analysis makes no reference whatsoever to my still very disabling lumbar spine problems (though it does point out incipient problems in four other major joints). Scans and X-rays are not magical, they do not automatically locate every possible form of spinal injury, sometimes spinal problems are only apparent during dynamic movement or at certain positions, not the neutral postures used for scans and x-rays, and often we have to fight for anything more than the most basic x-ray, and sometimes even that.

Even if we can get people to accept that our disabilities are real, we then face the difficulty of getting them to admit that they are actually disabling. Auntie Agatha may 'suffer terribly' with their back and run three marathons before breakfast, and everyone with an opinion is delighted to explain how they had a bad back once but worked through it, but the reality of long term spinal injuries is in an entirely different dimension to anything most people will ever have encountered. The problem we face is that pain is invisible and that long term pain doesn't go away, it's there one damned day after another. If you're dealing with it every day then whinging about being ill and in pain isn't an option, life goes on and I look the same whether I'm pain free or whether it feels like someone has rammed a dagger into my spine and is laying into it with a sledgehammer. We are often talking about degrees of pain that most people never imagine, never mind encounter, about feeling like bones are sheering apart, or like you have a second degree burn across substantial (and sensitive!) parts of your anatomy. Yes, there are painkillers we can take, all with their own side-effects, but they aren't a solution, when I talk about hammering daggers and extensive burns, those are the sensations with the opiates, not without!

'Surely there's an operation for that?' people ask. Not necessarily, is the unfortunate answer. There's that inconvenient absence of clear diagnoses, for one thing, it is difficult to know what to cut if you don't know what's causing the problem. Then there is the unfortunate reality that cutting may make it worse -- 'Failed Back-Surgery Syndrome' is a very real diagnostic label -- or cause problems at a different level of the spine - a common treatment is to fuse two or more vertebrae into a solid lump, but that simply causes extra stress to the joints on either side of the fusion. Then there are neuroplastic remodelling and Chronic Pain Syndrome, which are by definition independent of any musculo-skeletal clause. Similar problems occur with physiotherapy, which tends to be focussed on those simple pulled muscles and thrashes about in the dark when faced with any more complex problem. Over the years I've had back classes, traction, bracing, manipulation, hydrotherapy, you name it, they've tried it with me, but with no evidence of any joined-up thinking to link one set of treatment to another and try and work out a systematic approach. Eventually those of us who are lucky end up being referred to Chronic Pain Management teams. That is an explicit acknowledgement that the pain isn't going away, that the disability is here to stay and that no more active intervention is envisaged. Forget cure, hello coping.

So the next time Cameron, or Clegg, or Grayling are ranting about how ridiculous it is that people have dared to be disabled for more than 3 minutes without being cured, and there's that big set of statistics on the screen behind him, with 'depression' and 'bad back' highlighted for all to see, remember that the reality you need to consider isn't the one they're painting, it's mine.