Is Bad Posture the Cause of My Back Pain?

Most people attending the Physio Clinic with back pain believe that poor posture has played a significant role in their pain. Some clinicians spend a considerable amount of time analysing posture and attempting to link this to back pain.

The question is: Is there any Evidence for a link between poor posture and back pain?

In fact, there are two parts to answering this question:

1. Does the Evidence Show a Link Between Poor Posture & Pain?
2. Is there a Difference in Posture Between Individuals with & without Back Pain?

Laird RA, Gilbert J, Kent P, Keating JL. Comparing lumbo-pelvic kinematics in people with and without back pain: a systematic review and meta-analysis. BMC Musculoskelet Disord. 2014;15:229. Published 2014 Jul 10. doi:10.1186/1471-2474-15-229

This research review incorporated 8 different studies.
In summarising their findings, the authors found that, on average, people with low back pain had no difference in low back posture compared to those without low back pain.

Swain CTV, Pan F, Owen PJ, Schmidt H, Belavy DL. No consensus on causality of spine postures or physical exposure and low back pain: A systematic review of systematic reviews. J Biomech. 2020;102:109312. doi:10.1016/j.jbiomech.2019.08.006

Here, the authors found that some studies find a link between posture and back pain whereas others do not.
When only the higher quality studies are included then they could not find any consistent evidence for a link between back posture or physical activity and low back pain.

Can Bad Posture Cause of My Neck Pain?

Karen V Richards, D Clin Physio, M Manip Ther, Darren J Beales, PhD, M Manip Ther, Anne L Smith, PhD, M Biostatistics, Peter B O’Sullivan, PhD, Grad Dip Manip Ther, Leon M Straker, PhD B App Sc (Physio), Is Neck Posture Subgroup in Late Adolescence a Risk Factor for Persistent Neck Pain in Young Adults? A Prospective Study, Physical Therapy, Volume 101, Issue 3, March 2021, pzab007, https://doi.org/10.1093/ptj/pzab007

In this study with 686 participants, the authors found that sitting neck posture at 17 was not a risk factor for persistent neck pain at 22 years of age in males, whereas in females, more relaxed postures (slumped and intermediate postures) were protective of neck pain compared with upright posture.

The authors concluded that ‘the practice of generic public health messages to sit up straight to prevent neck pain needs rethinking.’

Is there a link between Poor Posture and Neck Pain?

Ariëns GA, Bongers PM, Douwes M, et al. Are neck flexion, neck rotation, and sitting at work risk factors for neck pain? Results of a prospective cohort study. Occup Environ Med. 2001;58(3):200-207. doi:10.1136/oem.58.3.200

This study followed a group of 1334 workers for a period of 3 years across 34 companies.

Work related physical load was assessed via video recordings of neck flexion, neck rotation, and sitting posture. Neck pain was assessed by a questionnaire.

‘A significant positive relation was found between the percentage of the working time in a sitting position and neck pain, implying an increased risk of neck pain for workers who were sitting for more than 95% of the working time.’

A trend for a positive relationship between neck flexion and neck pain was found, suggesting an increased risk of neck pain for people working with the neck at a minimum of 20° of flexion for more than 70% of the working time. No clear relation was found between neck rotation and neck pain.
‘Sitting at work for more than 95% of the working time seems to be a risk factor for neck pain and there is a trend for a positive relation between neck flexion and neck pain. No clear relation was found between neck rotation and neck pain.’

Do Movement Breaks Reduce the Incidence of Back Pain?

Waongenngarm P, Areerak K, Janwantanakul P. The effects of breaks on low back pain, discomfort, and work productivity in office workers: A systematic review of randomized and non-randomized controlled trials. Appl Ergon. 2018;68:230-239. doi:10.1016/j.apergo.2017.12.003

The authors in this study evaluated the effectiveness of active breaks on low back pain and productivity in office workers. They referred to all publications released over a 36 year period. 

The length of both working time and break times were highly variable between studies and therefore difficult to compare.

‘…..active breaks with postural change may be effective in reducing pain in workers with acute low back pain and to prevent discomfort in healthy subjects.’

The evidence also suggested that the use of breaks had no detrimental effect on work productivity.

Do Sit-To-Stand Desks Help to Reduce Back Pain?

Agarwal S, Steinmaus C, Harris-Adamson C. Sit-stand workstations and impact on low back discomfort: a systematic review and meta-analysis. Ergonomics. 2018;61(4):538-552. doi:10.1080/00140139.2017.1402960

Here, they identified eight relevant studies & concluded that sit-stand workstations, by leading to changes in posture may reduce low back pain among workers.
 

De Carvalho D, Greene R, Swab M, Godwin M. Does objectively measured prolonged standing for desk work result in lower ratings of perceived low back pain than sitting? A systematic review and meta-analysis. Work. 2020;67(2):431-440. doi:10.3233/WOR-203292

Prolonged sitting has been shown to induce transient low back pain. Height adjustable office desks now present the opportunity to replace sitting with standing in the workplace. Since standing has also been associated with back pain, this may not be an advisable alternative.

The results of three studies were pooled & the authors stated that:

‘prolonged standing postures during desk work did not induce significantly less perceived low back pain compared to seated postures.’

They concluded that ‘It appears that replacing seated desk work postures with standing for prolonged periods of time would not be recommended.’

My summary:
So, the evidence seems to be mixed when it comes to sitting or standing in terms of back pain prevention. Prolonged sitting, however, has several negative influences in terms of health. For example, prolonged sitting is associated with negative metabolic changes which can predispose to weight gain, diabetes and cardiovascular disease.

It appears that ‘active breaks’, where you are moving or performing exercise may be optimal for decreasing back pain incidence and improving overall health

Do Physical Jobs Increase the Risk of Back Pain?

Khan MI, Bath B, Boden C, Adebayo O, Trask C. The association between awkward working posture and low back disorders in farmers: a systematic review. J Agromedicine. 2019;24(1):74-89. doi:10.1080/1059924X.2018.1538918

Although studies of the general population have shown an association between low back disorders and awkward working posture, farmers have unique work context and exposures that may modify this relationship.

Nine studies were included in this review & they all used self-reported measures.

Despite the diversity, the weight of evidence supported a relationship between awkward posture and low back disorders.

My summary:
This particular study, using self-reports of poor posture, would be deemed very poor quality.
The authors concluded there may be a link between extremes of posture, as might occur in farming or heavy labour, but it is hard to be definitive from this study.

Roffey DM, Wai EK, Bishop P, Kwon BK, Dagenais S. Causal assessment of awkward occupational postures and low back pain: results of a systematic review. Spine J. 2010;10(1):89-99. doi:10.1016/j.spinee.2009.09.003

A systematic review was performed to identify a potential link between awkward occupational postures and LBP. Eight high-quality studies reported on awkward occupational postures and LBP.

The authors found ‘no association between awkward occupational postures and LBP, with only two studies demonstrating significant associations compared with six studies reported mainly nonsignificant associations.’

‘It is therefore unlikely that awkward occupational postures are independently causative of LBP in the populations of workers studied.’

Coenen P, Gouttebarge V, van der Burght AS, et al. The effect of lifting during work on low back pain: a health impact assessment based on a meta-analysis. Occup Environ Med. 2014;71(12):871-877. doi:10.1136/oemed-2014-102346

Lifting at work is considered an important risk factor for low back pain (LBP). However, contradictory findings have been reported, partly because frequency, duration and intensity (ie, the weight of the load) of lifting have not been systematically considered.

The aims of this study were: to assess the effect of lifting during work (quantified in duration, frequency or intensity) on the incidence of LBP and to quantify the impact of these relationships on the occurrence of LBP in occupational populations exposed to lifting.

Eight studies were included.

‘..we estimated that lifting loads over 25 kg and lifting at a frequency of over 25 lifts/day will increase the annual incidence of LBP by 4.32% and 3.50%, respectively, compared to the incidence of not being exposed to lifting.’ Intensity and frequency of lifting significantly predict the occurrence of LBP.

What Causes Back Pain in Cyclists?

Streisfeld GM, Bartoszek C, Creran E, Inge B, McShane MD, Johnston T. Relationship Between Body Positioning, Muscle Activity, and Spinal Kinematics in Cyclists With and Without Low Back Pain: A Systematic Review. Sports Health. 2017;9(1):75-79. doi:10.1177/1941738116676260

Low back pain is reported by more than half of cyclists. The causes of back pain in this group is not clearly understood.

Eight studies were included in this review.

Core muscle activation imbalances, back extensor endurance deficits, and increased lumbar flexion while cycling were found to be present in cyclists with low back pain.

My Summary of the Research:

• There is no clear link between poor posture and neck or back pain
  
• Prolonged sitting seems to be linked with back pain as opposed to the posture of sitting or type of chair
• Taking regular active breaks may help decrease back pain
• The evidence for using standing desks in terms of back pain is in its infancy but is unclear at present
• Awkward postures being assumed regularly during work does not show a clear link with back pain.
• Heavy manual labour seems to demonstrate an associated with an increase in back pain

It might be a case that, for some people, posture is a significant cause of their back pain, but because there are several factors that can cause pain, it might need to be present alongside other characteristics. When dealing with studies involving larger groups, this may not show up as statistically significant.

In other words: always keep an open mind!!

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How Do I Know If I Need Surgery For My Back Pain?

Low back pain has become a major health problem in the Western World with 1-year prevalence ranging from 22 to 65% (Walker 2000). 

In certain cases where back pain becomes chronic (lasting 12 weeks or longer) or when there are symptoms of severe nerve root compression secondary to a disc herniation, many people will end up having an orthopaedic referral. In some cases, this leads to the recommendation that back surgery is required.

I frequently see people who have been advised to undergo surgery for a disc herniation but are unsure as to whether they should or not. When it comes to a decision regarding whether spinal surgery is necessary, there are published guidelines to guide this decision-making process which we will highlight below.

In many cases however, the reality is that whether surgery is undertaken or not, is often a decision undertaken by the back pain sufferer themselves and is often based on whether they can cope with the pain or not. Generally speaking, since the 1980’s, the pendulum has swung in favour of non-surgical rehabilitation in the vast majority of back pain presentations.

There are some symptoms that indicate a significant compression of the spinal cord and necessitate surgery; however, these symptoms are extremely rare.

Criteria that necessitate the performance of immediate surgery include the following:

• Loss of bowel or bladder control eg incontinence or constipation
• Lack of sensation around the bum or genital region
• Instability while walking

What Does the Research Say About Back Surgery?

The most respected research group in healthcare are the Cochrane research group.
A Cochrane research review (Gibson et al. 1999) found no evidence that fusion surgery was effective for low back pain or degenerative disc disease.

Despite this, rates of lumbar spinal fusion increased 220% from 1990 to 2001 in the United States (Deyo et al. 2005)

Do I Need Surgery If I Have Sciatica?

Peul WC, van Houwelingen HC, van den Hout WB, Brand R, Eekhof JA, Tans JT, Thomeer RT, Koes BW; Leiden-The Hague Spine Intervention Prognostic Study Group. Surgery versus prolonged conservative treatment for sciatica. N Engl J Med. 2007 May 31;356(22):2245-56. doi: 10.1056/NEJMoa064039. PMID: 17538084.

In this study they randomly assigned 283 patients who had had severe sciatica for 6 to 12 weeks to early surgery (microdiscectomy) or to prolonged conservative (non-surgical) treatment with surgery if needed. 

Relief of leg pain was faster for patients assigned to early surgery.  

‘In both groups, however, the probability of perceived recovery after 1 year of follow-up was 95%.’

Gugliotta M, da Costa BR, Dabis E, Theiler R, Jüni P, Reichenbach S, Landolt H, Hasler P. Surgical versus conservative treatment for lumbar disc herniation: a prospective cohort study. BMJ Open. 2016 Dec 21;6(12):e012938. doi: 10.1136/bmjopen-2016-012938. PMID: 28003290; PMCID: PMC5223716.

‘We found no evidence that surgical treatment, when compared with conservative treatment, reduced the severity of sciatica symptoms or improved the quality of life of patients with lumber disc herniation in the medium or long term.
Pain was relieved more quickly in patients who received surgical treatment (evident at the 3-week follow-up), but the difference between groups was no longer present after 3 months.’

‘Compared with conservative treatment, surgical treatment relieved back pain faster, but no relevant clinical difference was observed after 3 months.’

Kreiner et al. (2012) North American Spine Society. Evidence-Based Clinical Guidelines for Multidisciplinary Spine Care.

Question: Are there clinical circumstances in which lumbar fusion is appropriate in the treatment of lumbar disc herniation with radiculopathy?

Answer: There is insufficient evidence to make a recommendation for or against fusion for specific patient populations with lumbar disc herniation with sciatica 

Grade of Recommendation: I (Insufficient Evidence)

The best evidence available suggests that outcomes are equivalent in patients with sciatica due to lumbar disc herniation whether or not a fusion is performed.

Is Surgery Effective for Chronic (Long-Term) Back Pain?

Brox. J. et al. Lumbar instrumented fusion compared with cognitive intervention and exercises in patients with chronic back pain after previous surgery for disc herniation: a prospective randomized controlled study. Pain. 2006 May;122(1-2):145-55. doi: 10.1016/j.pain.2006.01.027. Epub 2006 Mar 20. PMID: 16545523.

This study compared the effectiveness of lumbar fusion compared with a group performing exercise & who were educated regarding the importance of movement.
This time they took a group who had low back pain lasting longer than 1 year after previous surgery for a disc herniation.

One commonly used measure of disability is called the Oswestry Disability Index. Using this as a measure of outcome, they found that it was significantly improved from 47 to 38 after fusion and from 45 to 32 after exercise and education.

What About Surgical Fusion After Prior Failed Surgery?

Brox JI, Nygaard ØP, Holm I, Keller A, Ingebrigtsen T, Reikerås O. Four-year follow-up of surgical versus non-surgical therapy for chronic low back pain. Ann Rheum Dis. 2010 Sep;69(9):1643-8. doi: 10.1136/ard.2009.108902. Epub 2009 Jul 26. PMID: 19635718; PMCID: PMC2938881.

This study reported that lumbar fusion surgery was not superior to exercise rehabilitation and education in a group of chronic low back pain patients with and without previous surgery for a disc herniation.

In most studies of this nature, you find a certain percentage of people do not respond to rehabilitation. They will often undergo surgery at a later date. On the surface of it, this might appear to suggest that they would have fared better if they had undergone surgery in the first place. However, in this study they found that on follow-up there was a similar number of people in the surgery group undergoing re-operations as there was in the non-surgical group. This suggests that the group who do not improve, may not have improved, even if they had undergone surgery initially. 

124 patients with disc degeneration and at least 1 year of symptoms after or without previous surgery for disc herniation. 

What About the Risks from Back Surgery?

Cakir, Balkan et al. “Lumbar disk herniation: what are reliable criterions indicative for surgery?.”Orthopedics 32,8 (2009): 589. doi:10.3928/01477447-20090624-19              

In this prospective study, 126 patients with disc herniations were allocated randomly to surgical (60 patients) or conservative (66 patients) treatment.

At 1-year follow-up, patients operated on for a disc herniation showed better results compared to their conservative peers; however, this study indicates that there is no significant difference at medium- and long-term follow-up between surgical and nonsurgical treatment for disc herniation.

When comparing surgical and nonsurgical treatment options the obvious advantage of conservative treatment is the absence of complications related to surgery. Any surgical procedure, no matter how carefully performed, carries risks.

Common complications in diskectomy include wrong level surgery, missed pathology and/or retained herniation, dural leakage, epidural venous bleeding with epidural hematoma, iatrogenic instability with residual back pain, infection/diskitis, thromboembolism and postoperative epidural fibrosis.5

The reported intra- and postoperative complication rate varies between 3% and 25% for standard nucleotomy and between 2% and 11% in microsurgical diskectomy.6-10 An argument for nonoperative treatment is also the rate of reoperations after diskectomy. With regard to published data with sufficient follow-up and sound number of patients, the revision rate after diskectomy varies between 6% and 15%.9,11-13

Paul Willems (2013) Decision Making in Surgical Treatment of Chronic Low Back Pain: The performance of prognostic tests to select patients for lumbar spinal fusion, Acta Orthopaedica, 84:sup349, 1-37, DOI: 10.3109/17453674.2012.753565

Firstly, let’s highlight the fact that research suggests that non-invasive interventions, such as exercise therapy, produce similar results to spinal fusion, but ‘with considerably less complications, morbidity and costs.’ (1)

Fairbank, J. et al. Randomised controlled trial to compare surgical stabilisation of the lumbar spine with intensive rehabilitation. BMJ. 2005; 28;330(7502):1233.

Here, 349 patients with chronic low back pain of at least one year’s duration were selected to undergo either spinal fusion or an intensive rehabilitation programme

‘No clear evidence emerged that primary spinal fusion surgery was any more beneficial than intensive rehabilitation.’
“the potential risk and additional cost of surgery also need to be considered.”

Jacobs WC, van Tulder M, Arts M, Rubinstein SM, van Middelkoop M, Ostelo R, Verhagen A, Koes B, Peul WC. Surgery versus conservative management of sciatica due to a lumbar herniated disc: a systematic review. Eur Spine J. 2011 Apr;20(4):513-22. doi: 10.1007/s00586-010-1603-7. Epub 2010 Oct 15. PMID: 20949289; PMCID: PMC3065612.

They review the literature and state that most studies have a high risk of bias but the Wienstein study below does not. So what does the study by Weinstein & colleagues conclude?

Weinstein JN, Tosteson TD, Lurie JD, Tosteson AN, Hanscom B, Skinner JS, Abdu WA, Hilibrand AS, Boden SD, Deyo RA. Surgical vs nonoperative treatment for lumbar disk herniation: the Spine Patient Outcomes Research Trial (SPORT): a randomized trial. JAMA. 2006 Nov 22;296(20):2441-50. doi: 10.1001/jama.296.20.2441. PMID: 17119140; PMCID: PMC2553805.

The Spine Patient Outcomes Research Trial was a randomized clinical trial involving 501 surgical candidates from 13 multidisciplinary spine clinics in 11 US states.

In the group with sciatica and confirmed disc herniations it was shown that both the surgery as well as the conservative treatment group improved substantially over 2 years

Again, they suggest that early surgery in patients with sciatica may provide better short-term relief of leg pain but the evidence is low quality as only one trial investigated this properly.

After 2 years of follow-up, 45% of patients in the conservative treatment group underwent surgery and 40% in the surgery group received conservative treatment.

Should I Undergo Surgery for Lumbar Stenosis?

Lumbar stenosis is a narrowing of the spinal canal that can lead to compression of the nerves that supply gluteal & leg muscles.

Machado GC, Ferreira PH, Harris IA, Pinheiro MB, Koes BW, van Tulder M, Rzewuska M, Maher CG, Ferreira ML. Effectiveness of surgery for lumbar spinal stenosis: a systematic review and meta-analysis. PLoS One. 2015 Mar 30;10(3):e0122800. doi: 10.1371/journal.pone.0122800. PMID: 25822730; PMCID: PMC4378944.

Nineteen published reports (17 trials) were included in this systematic review.

The authors concluded that ‘The results of this Cochrane review show a paucity of evidence on the efficacy of surgery for lumbar spinal stenosis, as to date no trials have compared surgery with no treatment, placebo or sham surgery.’

Is Spinal Manipulation Effective for Treatment of a Lumbar Disc Herniation?

Santilli V, Beghi E, Finucci S. Chiropractic manipulation in the treatment of acute back pain and sciatica with disc protrusion: a randomized double-blind clinical trial of active and simulated spinal manipulations. Spine J. Mar-Apr 2006;6(2):131-137.

Santilli performed a randomized double-blind controlled trial assessing the short-and long-term effects of spinal manipulation on acute back pain and sciatica with disc protrusion.

Of 102 patients, 53 received manipulations and 49 received simulated manipulations. Manipulations appeared more effective on the basis of the percentage of pain-free cases:

local pain 28 vs. 6%; p<.005;

radiating pain 55 vs. 20%; p<.0001

Patients receiving manipulations had lower mean VAS1 (p<.0001) and VAS2 scores (p<.001).

‘This study provides Level I therapeutic evidence that spinal manipulation is significantly more effective than sham treatment for the relief of back and leg pain due to acute (less than 10 days) lumbar disc herniation with radiculopathy.’

There were no adverse events.

Should I Have Spinal Manipulation or Surgery for Sciatica?

McMorland G, Suter E, Casha S, du Plessis SJ, Hurlbert RJ. Manipulation or microdiskectomy for sciatica? A prospective randomized clinical study. J Manipulative Physiol er. 2010 Oct;33(8):576-584.

Patients referred by primary care physicians to neurosurgical spine surgeons were consecutively screened for symptoms of unilateral lumbar radiculopathy 

Forty consecutive patients who met inclusion criteria (patients must have failed at least 3 months of nonoperative management including treatment with analgesics, lifestyle modification, physiotherapy, massage therapy, and/or acupuncture) were randomized to either surgical microdiskectomy or chiropractic spinal manipulation.

Sixty percent of patients with sciatica who had failed other medical management benefited from spinal manipulation to the same degree as if they underwent surgical intervention.

They recommended that ‘patients with symptomatic lumbar disc herniation failing medical management should consider spinal manipulation followed by surgery if warranted.’

The manipulation group received an average of 21 treatment sessions & an additional 6 supervised rehabilitation sessions over the 52-week duration of the study. Patients in the surgical arm underwent a single microdiscectomy procedure followed by 6 supervised rehabilitation sessions over the 52-week duration of the study. No new neurological deficits arose from either of the treatment protocols nor were there any significant adverse events reported

Some orthopaedic guys have said that manipulation should be avoided. Is this accurate?

Well, in both the Sintilli & McMorland studies above there was not a single significant adverse effect reported.

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What is the Best Medication to Take for my Back Pain?

I am frequently asked by patients: ‘what drug should I take to ease my back pain?’ My normal response is to avoid taking them if possible, unless you are really finding it a struggle to sleep at night.

One of the most commonly available pain-killers is paracetamol, and, because most people already have some at home, it is often taken in an attempt to ease back pain.

One study reviewed all the published evidence in relation to using paracetamol to treat low back pain (1)

Based on the available evidence they concluded that: ‘paracetamol is ineffective in the treatment of low back pain and provides minimal short-term benefit for people with osteoarthritis.’

The UK National Institute for Health & Care Excellence (NICE) guidelines corroborated this and they no longer recommend paracetamol for back pain treatment.

What Anti-Inflammatory Drug Should I Take for My Back Pain?

The drugs that are most frequently used for treating back pain are the anti-inflammatory group of drugs. For decades, they formed the standard practice in treating back pain.

Because of the opioid crisis, the pharmaceutical industry are looking for alternative treatments for pain. One alternative is the use of non-steroidal anti-inflammatory drugs (NSAIDs). (5)

In the U.S. for example, around 60% of patients with osteoarthritis or chronic low back pain are prescribed NSAIDs.

In the UK, the National (NICE) guidelines recommend anti-inflammatories (NSAIDs) as the first choice for treating back pain & sciatica.

Anti-inflammatory drugs (NSAIDs) are commonly used for pain management. Common examples of include:

• Ibuprofen
• Diclofenac
• Celecoxib

The logic behind the use of anti-inflammatories is that decreasing inflammation will lead to a decrease in pain and speed up recovery. A common misconception amongst patients is that their back pain is caused by local inflammation. In the vast majority of back pain that I treat there is  no evidence of inflammation in the site of back pain.

Even in cases where inflammation is present, the question is:

Is inflammation harmful?
Does blocking inflammation improve healing?
How much inflammation is too much?
How long should I take anti-inflammatories for, if at all?

Should I take anti-inflammatories if I have a fracture?

It has been recognised for a long time that taking NSAIDs decreases bone healing and increase the rates of non-union of bones. Because of this, they are generally avoided after orthopaedic surgery.

Previous research in animals also suggests that anti-inflammatory drugs (NSAIDs) may delay wound healing (4,6).

The anti-inflammatories block prostaglandins which have been shown to play an important role in bone repair, which includes differentiation of osteoblast and osteoclast precursor cells (6)

If they block wound and bone healing, is this an indication that they may have a similar impact when it comes to spinal pain?

What is the Evidence for Anti-Inflammatories in Helping Back Pain?

Mancado & colleagues reviewed the available data on anti-inflammatory drugs for treating spinal pain. They included 35 high quality studies (known as randomised controlled trials). (3)

From analysing all the available research, they concluded that anti-inflammatories (NSAIDs) are effective in treating spinal pain; however, they are no more effective than using a placebo

They reported that 6 participants needed to be treated with NSAIDs, for one additional participant to achieve clinically important pain reduction.

Can Blocking Inflammation Lead to Long-Term Back Pain?

A recent study attempted to answer some of these questions by testing for inflammatory markers in blood samples from 98 patients with recent onset low back pain (2)

At follow-up 3 months later, when testing blood samples for inflammation, they found that participants whose pain had gone at 3 months demonstrated more inflammation on initial testing. Inflammation was indicated by the presence of a higher number of immune cells known as neutrophils.
In the group with persistent pain, there was no increase in inflammatory cells measured on initial testing.

Neutrophils are a type of immune cell that helps to fight infection and dominate in the the early stages of injury.

Here, the researchers found that blocking neutrophils in mice prolonged the pain up to ten times the normal duration. In mice, treating the pain with steroid or nonsteroidal anti-inflammatory drugs (NSAID) like diclofenac led to prolonged pain, despite helping to decrease pain in the short term. The mice were less sensitive to touch in the initial phase.

If the scientists administered neutrophils, then this prolonging of pain was reversed, showing that these immune cells are vital for recovery from back pain.

So, the presumption that decreasing swelling aids recovery needs to be re-evaluated in light of these findings.

As part of the study, they examined data of 500,000 people from the United Kingdom Biobank, a database of medical information. They found those taking anti-inflammatory drugs to treat their pain were much more likely to have pain two to ten years later.

They also found that taking painkillers, such as Tylenol were less likely to experience chronic pain compared to those who took anti-inflammatory medication.

Benefit & Risk From Taking Anti-Inflammatories

At present, there are no pain-killers that provide clinically important effects for spinal pain over placebo (3)

Even after all this is considered, ‘NSAIDs increased the risk of gastrointestinal reactions by 2.5 times’, contributing to 18,000 gastric bleeds each year in the UK, & contributing to over 2,000 deaths.

References:

• Machado GC, Maher CG, Ferreira PH, Pinheiro MB, Lin CW, Day RO, McLachlan AJ, Ferreira ML. Efficacy and safety of paracetamol for spinal pain and osteoarthritis: systematic review and meta-analysis of randomised placebo controlled trials. BMJ. 2015 Mar 31;350:h1225. doi: 10.1136/bmj.h1225. PMID: 25828856; PMCID: PMC4381278.
• Parisien M, Lima LV, Dagostino C, El-Hachem N, Drury GL, Grant AV, Huising J, Verma V, Meloto CB, Silva JR, Dutra GGS, Markova T, Dang H, Tessier PA, Slade GD, Nackley AG, Ghasemlou N, Mogil JS, Allegri M, Diatchenko L. Acute inflammatory response via neutrophil activation protects against the development of chronic pain. Sci Transl Med. 2022 May 11;14(644):eabj9954. doi: 10.1126/scitranslmed.abj9954. Epub 2022 May 11. PMID: 35544595.
• MachadoGC, Maher CG, Ferreira PH, et al. Non-steroidal anti-inflammatory drugs for spinal pain: a systematic review and meta-analysis. Annals of the Rheumatic Diseases 2017;76:1269-1278.
• Nagano A, Arioka M, Takahashi-Yanaga F, Matsuzaki E, Sasaguri T. Celecoxib inhibits osteoblast maturation by suppressing the expression of Wnt target genes. J Pharmacol Sci. 2017;133(1):18–24.
• Zhao-Fleming, H., Hand, A., Zhang, K. et al.Effect of non-steroidal anti-inflammatory drugs on post-surgical complications against the backdrop of the opioid crisis. Burn Trauma 6, 25 (2018). https://doi.org/10.1186/s41038-018-0128-x
• Jeffcoach DR, Sams VG, Lawson CM, Enderson BL, Smith ST, Kline H, et al. Nonsteroidal anti-inflammatory drugs’ impact on nonunion and infection rates in long-bone fractures. J Traum Acute Care Surg. 2014;76(3):779–83.