Surgery won’t fix my chronic back pain, so what will?
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This week’s ABC Four Corners episode Pain Factory highlighted that our health system is failing Australians with chronic pain. Patients are receiving costly, ineffective and risky care instead of effective, low-risk treatments for chronic pain.
The challenge is considering how we might reimagine health-care delivery so the effective and safe treatments for chronic pain are available to millions of Australians who suffer from chronic pain.
One in five Australians aged 45 and over have chronic pain (pain lasting three or more months). This costs an estimated A$139 billion a year, including $12 billion in direct health-care costs.
The most common complaint among people with chronic pain is low back pain. So what treatments do – and don’t – work?
Opioids and invasive procedures
Treatments offered to people with chronic pain include strong pain medicines such as opioids and invasive procedures such as spinal cord stimulators or spinal fusion surgery. Unfortunately, these treatments have little if any benefit and are associated with a risk of significant harm.
Spinal fusion surgery and spinal cord stimulators are also extremely costly procedures, costing tens of thousands of dollars each to the health system as well as incurring costs to the individual.
Addressing the contributors to pain
Recommendations from the latest Australian and World Health Organization clinical guidelines for low back pain focus on alternatives to drug and surgical treatments such as:
- education
- advice
- structured exercise programs
- physical, psychological or multidisciplinary interventions that address the physical or psychological contributors to ongoing pain.
Two recent Australian trials support these recommendations and have found that interventions that address each person’s physical and psychological contributors to pain produce large and sustained improvements in pain and function in people with chronic low back pain.
The interventions have minimal side effects and are cost-effective.
In the RESOLVE trial, the intervention consists of pain education and graded sensory and movement “retraining” aimed to help people understand that it’s safe to move.
In the RESTORE trial, the intervention (cognitive functional therapy) involves assisting the person to understand the range of physical and psychological contributing factors related to their condition. It guides patients to relearn how to move and to build confidence in their back, without over-protecting it.
Why isn’t everyone with chronic pain getting this care?
While these trials provide new hope for people with chronic low back pain, and effective alternatives to spinal surgery and opioids, a barrier for implementation is the out-of-pocket costs. The interventions take up to 12 sessions, lasting up to 26 weeks. One physiotherapy session can cost $90–$150.
In contrast, Medicare provides rebates for just five allied health visits (such as physiotherapists or exercise physiologists) for eligible patients per year, to be used for all chronic conditions.
Private health insurers also limit access to reimbursement for these services by typically only covering a proportion of the cost and providing a cap on annual benefits. So even those with private health insurance would usually have substantial out-of-pocket costs.
Access to trained clinicians is another barrier. This problem is particularly evident in regional and rural Australia, where access to allied health services, pain specialists and multidisciplinary pain clinics is limited.
Higher costs and lack of access are associated with the increased use of available and subsidised treatments, such as pain medicines, even if they are ineffective and harmful. The rate of opioid use, for example, is higher in regional Australia and in areas of socioeconomic disadvantage than metropolitan centres and affluent areas.
So what can we do about it?
We need to reform Australia’s health system, private and public, to improve access to effective treatments for chronic pain, while removing access to ineffective, costly and high-risk treatments.
Better training of the clinical workforce, and using technology such as telehealth and artificial intelligence to train clinicians or deliver treatment may also improve access to effective treatments. A recent Australian trial, for example, found telehealth delivered via video conferencing was as effective as in-person physiotherapy consultations for improving pain and function in people with chronic knee pain.
Advocacy and improving the public’s understanding of effective treatments for chronic pain may also be helpful. Our hope is that coordinated efforts will promote the uptake of effective treatments and improve the care of patients with chronic pain.
Christine Lin, Professor, University of Sydney; Christopher Maher, Professor, Sydney School of Public Health, University of Sydney; Fiona Blyth, Professor, University of Sydney; James Mcauley, Professor of Psychology, UNSW Sydney, and Mark Hancock, Professor of Physiotherapy, Macquarie University
This article is republished from The Conversation under a Creative Commons license. Read the original article.
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Alzheimer’s Causative Factors To Avoid
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The Best Brains Bar Nun?
This is Dr. David Snowdon. He’s an epidemiologist, and one of the world’s foremost experts on Alzheimer’s disease. He was also, most famously, the lead researcher of what has become known as “The Nun Study”.
We recently reviewed his book about this study:
…which we definitely encourage you to check out, but we’ll do our best to summarize its key points today!
Reassurance up-front: no, you don’t have to become a nun
The Nun Study
In 1991, a large number (678) of nuns were recruited for what was to be (and until now, remains) the largest study of its kind into the impact of a wide variety of factors on aging, and in particular, Alzheimer’s disease.
Why it was so important: because the nuns were all from the same Order, had the same occupation (it’s a teaching Order), with very similar lifestyles, schedules, socioeconomic status, general background, access to healthcare, similar diets, same relationship status (celibate), same sex (female), and many other factors also similar, this meant that most of the confounding variables that confound other studies were already controlled-for here.
Enrollment in the study also required consenting to donating one’s brain for study post-mortem—and of those who have since died, indeed 98% of them have been donated (the other 2%, we presume, may have run into technical administrative issues with the donation process, due to the circumstances of death and/or delays in processing the donation).
How the study was undertaken
We don’t have enough space to describe the entire methodology here, but the gist of it is:
- Genetic testing for relevant genetic factors
- Data gathered about lives so far, including not just medical records but also autobiographies that the nuns wrote when they took their vows (at ages 19–21)
- Extensive ongoing personal interviews about habits, life choices, and attitudes
- Yearly evaluations including memory tests and physical function tests
- Brain donation upon death
What they found
Technically, The Nun Study is still ongoing. Of the original 678 nuns (aged 75–106), three are still alive (based on the latest report, at least).
However, lots of results have already been gained, including…
Genes
A year into the study, in 1992, the “apolipoprotein E” (APOE) gene was established as a likely causative factor in Alzheimer’s disease. This is probably not new to our readers in 2024, but there are interesting things being learned even now, for example:
The Alzheimer’s Gene That Varies By Race & Sex
…but watch out! Because also:
Alzheimer’s Sex Differences May Not Be What They Appear
Words
Based on the autobiographies written by the nuns in their youth upon taking their vows, there were two factors that were later correlated with not getting dementia:
- Longer sentences
- Positive outlook
- “Idea density”
That latter item means the relative linguistic density of ideas and complexity thereof, and the fluency and vivacity with which they were expressed (this was not a wishy-washy assessment; there was a hard-science analysis to determine numbers).
Want to spruce up yours? You might like to check out:
Reading, Better: Reading As A Cognitive Exercise
…for specific, evidence-based ways to tweak your reading to fight cognitive decline.
Food
While the dietary habits of the nuns were fairly homogenous, those who favored eating more and cooked greens, beans, and tomatoes, lived longer and with healthier brains.
See also: Brain Food? The Eyes Have It!
Other aspects of brain health & mental health
The study also found that nuns who avoided stroke and depression, were also less likely to get dementia.
For tending to these, check out:
- Two Things You Can Do To Improve Stroke Survival Chances
- Depression, And The Mental Health First-Aid That You’ll Hopefully Never Need
- Behavioral Activation Against Depression & Anxiety
Community & Faith
Obviously, in this matter the nuns were quite a homogenous group, scoring heavily in community and faith. What’s relevant here is the difference between the nuns, and other epidemiological studies in other groups (invariably not scoring so highly).
Community & faith are considered, separately and together, to be protective factors against dementia.
Faith may be something that “you have it or you don’t” (we’re a health science newsletter, not a theological publication, but for the interested, philosopher John Stuart Mill’s 1859 essay “On Liberty“ makes a good argument for it not being something one can choose, prompting him to argue for religious tolerance, on the grounds that religious coercion is a futile effort precisely because a person cannot choose to dis/believe something)
…but community can definitely be chosen, nurtured, and grown. We’ve written about this a bit before:
You might also like to check out this great book on the topic:
Purpose: Design A Community And Change Your Life – by Gina Bianchini
Want more?
We gave a ground-up primer on avoiding Alzheimer’s and other dementias; check it out:
How To Reduce Your Alzheimer’s Risk
Take care!
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Lifestyle vs Multiple Sclerosis & More
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This is Dr. Saray Stancic. She’s another from the ranks of “doctors who got a serious illness and it completely changed how they view the treatment of serious illness”.
In her case, Stancic was diagnosed with multiple sclerosis, and wasn’t impressed with the results from the treatments offered, so (after 8 years of pain, suffering, and many medications, only for her condition to worsen) she set about doing better with an evidence-based lifestyle medicine approach.
After 7 years of her new approach, she would go on to successfully run a marathon and live symptom-free.
All this to say: her approach isn’t a magic quick fix, but it is a serious method for serious results, and after all, while it’d be nice to be magically in perfect health tomorrow, what’s important is being in good health for life, right?
If you’re interested in her impressive story, check out:
Doctor With Multiple Sclerosis On The Collapse Of US Healthcare
If you want to know what she did, then read on…
Six key lifestyle changes
Dr. Stancic credits her recovery to focus on the following evidence-based approaches:
The plant-centered plate
This is critical, and is the one she places most emphasis on. Most chronic diseases are exacerbated, if not outright caused, by chronic inflammation, and one cannot fix that without an anti-inflammatory diet.
An anti-inflammatory diet doesn’t have to be 100% plant-based, but broadly speaking, plants are almost always anti-inflammatory to a greater or lesser degree, while animal products are often pro-inflammatory—especially red meat and unfermented dairy.
For more details, see:
Anti-Inflammatory Diet 101 (What to Eat to Fight Inflammation)
Movement every day
While “exercise is good for you” is in principle not a shocker, remember that her starting point was being in terrible condition with badly flared-up MS.
Important to understand here is that excessive exercise can weaken the immune system and sometimes cause flare-ups of various chronic diseases.
Moving thoroughly and moving often, however, is best. So walking yes, absolutely, but also don’t neglect the rest of your body, do some gentle bodyweight squats (if you can; if you can’t, work up to them), stretch your arms as well as your legs, take all your joints through a full range of motion.
See also:
The Doctor Who Wants Us To Exercise Less, & Move More
Mindful stress management
Stress in life is unavoidable, but how we manage it is up to us. Bad things will continue to happen, great and small, but we can take a deep breath, remember that those things aren’t the boss of us, and deal with it calmly and conscientiously.
Mindfulness-Based Stress Reduction is of course the evidence-based “gold standard” for this, but whatever (not substance-based) method works for you, works for you!
About MBSR:
No-Frills, Evidence-Based Mindfulness
Good sleeping habits
Getting good sleep can be hard for anyone, let alone if you have chronic pain. However, Dr. Stancic advocates for doing whatever we can to get good sleep—which means not just duration (the famous “7–9 hours”), but also quality.
Learn more:
The 6 Dimensions Of Sleep (And Why They Matter)
Substance intake awareness
This one’s not so much of a “don’t do drugs, kids” as the heading makes it look. Dr. Stancic assumes we already know, for example, that smoking is bad for us in a long list of ways, and alcohol isn’t much better.
However, she also advises us that in our eagerness to do that plant-based diet, we would do better to go for whole foods plant-based, rather than the latest processed meat substitutes, for example.
And supplements? She bids us exercise caution, and to make sure to get good quality, as poor quality supplements can be worse than taking nothing (looking at you, cheap turmeric supplements that contain heavy metals).
And of course, that nutrients gained from diet will almost always be better than nutrients gained from supplements, as our body can usually use them better.
And see also, some commonly-made supplements mistakes:
Do You Know Which Supplements You Shouldn’t Take Together? (10 Pairs!)
Human connection
Lastly, we humans are a social species by evolution; as individuals, we may enjoy relatively more or less social contact, but having access to such is important not just for our mental health, but our physical health too—we will tend to deteriorate much more quickly when we have to deal with everything alone, all other things being equal.
It doesn’t mean you need a busy social life if that’s not in your nature, but it does mean it’s incredibly beneficial to have at least a small number of people that you trust and whose company you enjoy, at least relatively accessible to you (i.e., their life need not revolve around you, but they are the kind of people who will generally happily spend time with you and provide support when needed if they can).
As for how:
How To Beat Loneliness & Isolation
Want to know more from Dr. Stancic?
We recently reviewed this very good book of hers, which goes over each of these six things in much more detail than we have room for here:
What’s Missing from Medicine – by Dr. Saray Stancic
Enjoy!
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Lose Weight (Healthily!)
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What Do You Have To Lose?
For something that’s a very commonly sought-after thing, we’ve not yet done a main feature specifically about how to lose weight, so we’re going to do that today, and make it part of a three-part series about changing one’s weight:
- Losing weight (specifically, losing fat)
- Gaining weight (specifically, gaining muscle)
- Gaining weight (specifically, gaining fat)
And yes, that last one is something that some people want/need to do (healthily!), and want/need help with that.
There will be, however, no need for a “losing muscle” article, because (even though sometimes a person might have some reason to want to do this), it’s really just a case of “those things we said for gaining muscle? Don’t do those and the muscle will atrophy naturally”.
One reason we’ve not covered this before is because the association between weight loss and good health is not nearly so strong as the weight loss industry would have you believe:
And, while BMI is not a useful measure of health in general, it’s worth noting that over the age of 65, a BMI of 27 (which is in the high end of “overweight”, without being obese) is associated with the lowest all-cause mortality:
BMI and all-cause mortality in older adults: a meta-analysis
Important: the above does mean that for very many of our readers, weight loss would not actually be healthy.
Today’s article is intended as a guide only for those who are sure that weight loss is the correct path forward. If in doubt, please talk to your doctor.
With that in mind…
Start in the kitchen
You will not be able to exercise well if your body is malnourished.
Counterintuitively, malnourishment and obesity often go hand-in-hand, partly for this reason.
Important: it’s not the calories in your food; it’s the food in your calories
See also: Mythbusting Calories
The kind of diet that most readily produces unhealthy overweight, the diet that nutritional scientists often call the “Standard American Diet”, or “SAD” for short, is high on calories but low on nutrients.
So you will want to flip this, and focus on enjoying nutrient-dense whole foods.
The Mediterranean Diet is the current “gold standard” in this regard, so for your interest we offer:
Four Ways To Upgrade The Mediterranean Diet
And since you may be wondering:
Should You Go Light Or Heavy On Carbs?
The dining room is the next most important place
Many people do not appreciate food enough for good health. The trick here is, having prepared a nice meal, to actually take the time to enjoy it.
It can be tempting when hungry (or just plain busy) to want to wolf down dinner in 47 seconds, but that is the metabolic equivalent of “oh no, our campfire needs more fuel, let’s spray it with a gallon of gasoline”.
To counter this, here’s the very good advice of Dr. Rupy Aujla, “The Kitchen Doctor”:
Interoception & Mindful Eating
The bedroom is important too
You snooze, you lose… Visceral belly fat, anyway! We’ve talked before about how waist circumference is a better indicator of metabolic health than BMI, and in our article about trimming that down, we covered how good sleep is critical for one’s waistline:
Visceral Belly Fat & How To Lose It
Exercise, yes! But in one important way.
There are various types of exercise that are good for various kinds of health, but there’s only one type of exercise that is good for boosting one’s metabolism.
Whereas most kinds of exercise will raise one’s metabolism while exercising, and then lower it afterwards (to below its previous metabolic base rate!) to compensate, high-intensity interval training (HIIT) will raise your metabolism while training, and for two hours afterwards:
…which means that unlike most kinds of exercise, HIIT actually works for fat loss:
So if you’d like to take up HIIT, here’s how:
How (And Why) To Do HIIT (Without Wrecking Your Body)
Want more?
Check out our previous article about specifically how to…
Burn! How To Boost Your Metabolism
Take care!
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ADHD… As An Adult?
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ADHD—not just for kids!
Consider the following:
- If a kid has consistent problems paying attention, it’s easy and common to say “Aha, ADHD!”
- If a young adult has consistent problems paying attention, it’s easy and common to say “Aha, a disinterested ne’er-do-well!”
- If an older adult has consistent problems paying attention, it’s easy and common to say “Aha, a senior moment!”
Yet, if we recognize that ADHD is fundamentally a brain difference in children (and we do; there are physiological characteristics that we can test), and we can recognize that as people get older our brains typically have less neuroplasticity (ability to change) than when we are younger rather than less, then… Surely, there are just as many adults with ADHD as kids!
After all, that rather goes with the linear nature of time and the progressive nature of getting older.
So why do kids get diagnoses so much more often than adults?
Parents—and schools—can find children’s ADHD challenging, and it’s their problem, so they look for an explanation, and ADHD isn’t too difficult to find as a diagnosis.
Meanwhile, adults with ADHD have usually developed coping mechanisms, have learned to mask and/or compensate for their symptoms, and we expect adults to manage their own problems, so nobody’s rushing to find an explanation on their behalf.
Additionally, the stigma of neurodivergence—especially something popularly associated with children—isn’t something that many adults will want for themselves.
But, if you have an ADHD brain, then recognizing that (even if just privately to yourself) can open the door to much better management of your symptoms… and your life.
So what does ADHD look like in adults?
ADHD involves a spread of symptoms, and not everyone will have them all, or have them in the same magnitude. However, very commonly most noticeable traits include:
- Lack of focus (ease of distraction)
- Conversely: high focus (on the wrong things)
- To illustrate: someone with ADHD might set out to quickly tidy the sock drawer, and end up Marie Kondo-ing their entire wardrobe… when they were supposed to doing something else
- Conversely: high focus (on the wrong things)
- Poor time management (especially: tendency to procrastinate)
- Forgetfulness (of various kinds—for example, forgetting information, and forgetting to do things)
Want To Take A Quick Test? Click Here ← this one is reputable, and free. No sign in required; the test is right there.
Wait, where’s the hyperactivity in this Attention Deficit Hyperactivity Disorder?
It’s often not there. ADHD is simply badly-named. This stems from how a lot of mental health issues are considered by society in terms of how much they affect (and are observable by) other people. Since ADHD was originally noticed in children (in fact being originally called “Hyperkinetic Reaction of Childhood”), it ended up being something like:
“Oh, your brain has an inconvenient relationship with dopamine and you are driven to try to correct that by shifting attention from boring things to stimulating things? You might have trouble-sitting-still disorder”
Hmm, this sounds like me (or my loved one); what to do now at the age of __?
Some things to consider:
- If you don’t want medication (there are pros and cons, beyond the scope of today’s article), you might consider an official diagnosis not worth pursuing. That’s fine if so, because…
- More important than whether or not you meet certain diagnostic criteria, is whether or not the strategies recommended for it might help you.
- Whether or not you talk to other people about it is entirely up to you. Maybe it’s a stigma you’d rather avoid… Or maybe it’ll help those around you to better understand and support you.
- Either way, you might want to learn more about ADHD in adults. Today’s article was about recognizing it—we’ll write more about managing it another time!
In the meantime… We recommended a great book about this a couple of weeks ago; you might want to check it out:
Click here to see our review of “The Silent Struggle: Taking Charge of ADHD in Adults”!
Note: the review is at the bottom of that page. You’ll need to scroll past the video (which is also about ADHD) without getting distracted by it and forgetting you were there to see about the book. So:
- Click the above link
- Scroll straight to the review!
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Great Sex Never Gets Old – by Kimberly Cunningham – by Kimberly Cunningham
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Here some readers may be thinking “after 40? But I am 70 already” or such, so be assured, there’s no upper limit on the applicability of this book’s writings. The number of 40 was chosen more as the start point of things, because it is an age after which the majority of hormonal declines happen (and with them, often, sex drive and/or physical ability). But, as she explains, this is by no means necessarily an end, and can instead be an exciting new beginning.
She kicks things off with a “wellness check”, before diving into the science of the menopause—and yes, the andropause too.
She doesn’t stop there though, and discusses other hormones besides the obvious ones, and other non-hormonal factors that can affect sex in what for most people is the later half of life.
Nurse Cunningham, much like most of modern science, is strongly pro-HRT, and/but doesn’t claim it to be a magic bullet (though honestly, it can feel like it is! But here we’re reviewing the book, not HRT, so let’s continue), or else this book could have been a leaflet. Instead, she talks about the side-effects to expect (mostly good or neutral, but still, things you don’t want to be taken by surprise by), and what things will just be “a little different” now if you’re running on exogenous bioidentical hormones rather than ones your own body made. A lot of this comes down to how and when one takes them, by the way, since this can be different to your body making its own natural peaks and troughs.
But it’s not all about hormones; there are also plenty of chapters on social and psychological issues, as well as medical issues other than hormones.
The style is very light and conversational, while also casually dropping about 30 pages of scientific references. Like many nurses, the author knows at least as much as doctors when it comes to her area of expertise, and it shows.
Bottom line: if your sex has ever hit a slump, and/or you simply recognize that it could, this book could make a very important difference.
Click here to check out Great Sex Never Gets Old, and enjoy the best of life in the bedroom too!
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Eye Drops: Safety & Alternatives
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It’s Q&A Day at 10almonds!
Have a question or a request? You can always hit “reply” to any of our emails, or use the feedback widget at the bottom!
In cases where we’ve already covered something, we might link to what we wrote before, but will always be happy to revisit any of our topics again in the future too—there’s always more to say!
As ever: if the question/request can be answered briefly, we’ll do it here in our Q&A Thursday edition. If not, we’ll make a main feature of it shortly afterwards!
So, no question/request too big or small
❝Before important business meetings my father used to use eye drops to add a “sparkle” to his eyes. I think that is a step too far, but what, short of eye drops, can we do to keep our eyes bright throughout the day?❞
Firstly, we’d indeed not recommend eye drops unless advised to do so by your doctor to treat a specific health condition:
- Infections from over-the-counter artificial tears
- Are my eye drops safe to use?
- More eye drops recalled due to infection danger
Those eye drops that “add sparkle” are often based on astringents such as witch hazel. This means that the capillaries in the eye undergo vasoconstriction, becoming much less visible and the eye thus appears much whiter and thus brighter.
There isn’t a way to do the same thing from the inside, as taking a vasoconstrictor will simply increase your general blood pressure, making the capillaries of your eyes more, rather than less, visible.
However, what you can do is…
- look after your general vasculature (cardiovascular health)
- in particular, reduce hypertension
- that includes limiting salt
- stay away from vasoconstrictors (including caffeine)
- reduce your resting cortisol levels
- that certainly also means reducing alcohol consumption
- maintain good hydration
Take care!
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