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BRITISH BROADCASTING CORPORATION
RADIO SCIENCE UNIT
CASE NOTES
Programme 3. - Backs
RADIO 4
TUESDAY 24/01/06 2100-2130
PRESENTER:
MARK PORTER
CONTRIBUTORS:
STEPHEN LONGWORTH
PETER MOORE
CHARLES PITHER
CAROLINE JOHNSTON
CLAIRE DANIEL
MICHAEL GREVITT
PRODUCER:
ADRIAN WASHBOURNE
NOT CHECKED AS BROADCAST
PORTER
Hello. Today's programme is all about back pain - a topical subject given that the government have just announced proposals for reducing the 拢12.5 billion spent every year on incapacity benefit to people who can't work because of illness.
Back pain is the biggest single medical cause of time off work - accounting for nearly half of all sickness related absence from the workplace, that's just over 50 million lost working days every year.
But back pain doesn't just cause time off work - as many as half of us will suffer from at least one episode every year, and around 5 million people will end up at their GPs.
I'll be finding out how to differentiate a simple sprain or strain that will settle with time, from something more sinister that warrants active intervention.
We'll also be hearing from someone who had back trouble for years and whose life has been transformed by a self-help pain management programme - even though a whole range of different therapists had previously been unable to help him.
CLIP
I went doctor shopping and therapy shopping and in fact everybody with an ist or an ology at the end of their name, I went and saw. And I spent about 拢8,000 on those sort of people - osteopaths, chiropractors, physios, reflexologists, aromatherapists.
PORTER
And I'll be talking to a spinal surgeon to find out about the pros and cons of a surgical approach to back pain - and why that needn't actually involve going under the knife.
My guest today is Steve Longworth, a GP with a special interest in back pain. Steve, you do a back clinic once a week, what sort of people are you seeing?
LONGWORTH
Well in a typical clinic I'll see a whole age range really, from perhaps the teenager with a bendy back, a scoliosis, that may or may not need surgery, perhaps to someone in their 80s who has got wear and tear changes in the bottom of their back that causes a condition called spinal stenosis, this makes your legs turn to jelly and all the power drain away when you walk around and it's very distressing. We often see people with sciatica, that's nerve pain going down the leg, often as far as the foot and the ankle and that perhaps to middle age people. But most frequently, I guess, we see people with common or garden back pain that's just not getting better.
PORTER
Sent in by people like me because I mean that's what we're seeing in the general practice and what we call common or garden back pain. What's actually causing that?
LONGWORTH
Well that's a very interesting question because surprisingly and frustratingly we cannot say for certain where most, what we call, mechanical back pain actually originates. At different times it probably comes from the joints, the ligaments, the muscles and the discs in the back. But for any one individual patient on any one individual occasion it's difficult, if not impossible, to actually say what the source of the pain is.
PORTER
And this mechanical back pain is by far the most common group of back pains, it accounts for the majority of cases we see?
LONGWORTH
Ninety per cent of the back pain that I'll see in general practice will be of this category.
PORTER
And signs and symptoms of that would be?
LONGWORTH
People come along with often pain that started suddenly when they've been doing something ordinary, perhaps after a bout of gardening, people tell you that they bent over to pick up a pen and suddenly their back's gone twang and they feel pain across the lower back, it may spread as far as their buttocks and sometimes as far as one of their thighs but typically it's in the lower region of the back below the ribs on one or both sides or sometimes in the middle.
PORTER
And left to its own devices how much of a problem will it cause for them and for how long?
LONGWORTH
Well fortunately most people get better spontaneously and this is the good news about mechanical back pain because even though we don't know precisely where it's coming from this doesn't actually matter for the majority of patients because we can recognise the pattern of symptoms and physical findings in someone who's got back pain and we can recognise when it's not serious and we can be really positive about managing this for our patients, we can give them lots of positive messages, tell them not to lie down and rest. When I was a lad 25 years ago when I first started that was the management - you said to people go and lie down - and in fact that's been shown to be an absolute disaster. So we give people lots of positive messages - it hurts but it's not harming, the pain doesn't mean serious damage, use it or lose it and get going.
PORTER
We'll come back to the exercise bit and work a little later if I may but what about tests, a lot of people come in to see me, they've got some back pain, maybe they've had it a week or two and some people actually come in and say what about an x-ray doc, why aren't you x-raying it.
LONGWORTH
Well that's a very good question. I had an episode of back pain myself about 15 years ago and after a couple of weeks you think good grief I'm never going to get better and you start worrying it's something serious that's going on. What we look for when we see somebody with back pain that isn't settling down are what we call red flags. So red flags are things that the patient tells us, that we know about them from their past medical history, that we find on examination that indicate that they might have a possible serious disease and if they have some of these red flags we may possibly arrange for some blood tests or an x-ray or a scan. But the overwhelming majority of people don't have them and don't need these tests do they.
PORTER
Well let's have a look, give me some examples of some of the red flags.
LONGWORTH
Well these would be things like people whose back pain starts under the age of 20 or over the age of 55, mechanical back pain, common or garden back pain, is a problem of the middle aged and actually gets less frequent as you get beyond 55. So someone whose back pain started at a very young age or someone say in their 80s who gets back pain for the first time it's highly likely not to be common or garden back pain. If someone's had a severe injury, like they've been knocked down by a van or fallen from a great height, for example, on to their back, if they have pain that's continuous, steadily getting worse, keeping them awake, doesn't seem to be helped by simple painkillers, if they've got a past history of a cancer, particularly things like lung, breast, prostate, kidney cancer - these sorts of cancers - that might spread to bone the back's a common place for what we call metastases or secondary cancers. And people who are generally unwell with weight loss and feeling rotten in themselves. Most people with mechanical back pain, although it hurts, they're usually very well.
PORTER
And what's the harm in doing an x-ray or some form of scan in people who don't necessarily have these red flags because a lot of people say well I understand the red flags will pick up - but I want to be on the safe side?
LONGWORTH
Well x-rays are very insensitive tests and there's a very poor correlation between people's symptoms, the seriousness of what's going on and anything you might see on an x-ray. The difficulty with MRI scanning, which is the most modern form of imaging for back pain, is that it's too sensitive, it shows us absolutely everything, which is great but it also shows up lots of irrelevancies. And we have a saying in the spine clinic where I work which is to treat the man not the scan. If your symptoms, the things we find when we examine you and the scan all fit together that's great but primarily we treat patients not pictures.
PORTER
Well as Steve said the outlook for most people is good but Pete Moore wasn't one of the lucky ones, he suffered for years before he enrolled in the Input pain management programme at St Thomas' Hospital in London where he learnt to manage the pain himself and take back control of his life. His problems came to a head 14 years ago when he was decorating a house in Windsor, the day the Castle caught fire.
MOORE
When I went home from work that evening I felt my back was a bit more sore than normal but the next day I couldn't even get out of bed and that's when I found out that I'd prolapsed a couple of discs in my lower back.
PORTER
And presumably they were pressing on the nerves - what were you getting sciatica pain into the legs ...?
MOORE
Yeah, I just - I just couldn't [indistinct word], I was having trouble just getting out of bed generally and even just going to the loo.
PORTER
So you'd been having problems for a long time, had you been going back and forth to your GP?
MOORE
Yeah I was - I suppose in a way like most patients give us a pill to try and fix the problem really, I didn't really realise in those days that I had to take a bit of management myself.
PORTER
So what happened when things took a turn for the worst?
MOORE
I was stuck getting bounced around the system really, having physiotherapy, then an MRI scan - I had to wait nearly nine months for an MRI scan. The consultant at the time, as I found out, used inappropriate sort of language and he told me that my spine was like a digestive biscuit and if anybody's told that their spine was like a digestive biscuit you wouldn't want to move because you think well to do more activity would cause my problem to increase.
PORTER
And by suggesting it was like a biscuit he was suggesting that it was very fragile?
MOORE
Yeah, very fragile, crumbling yeah. I mean I've heard other terms since then where doctors have said my spine is crumbling, easy does it and even today I'm aware of people telling me that doctors are still telling them to take bed rest, which is, as I found out, the - actually by resting was actually making my problem worse.
PORTER
And what were you doing to try and help yourself, were you trying any other type of therapy?
MOORE
Yeah I was like most people really I went doctor shopping and therapy shopping and in fact everybody with an ist or an ology at the end of their name I went and saw and I spent about 拢8,000 on those sort of people - osteopaths, chiropractors, physios, reflexologists, aromatherapists - you know as a self employed person I need to work I need to earn money but the actual pain took over my life, I suppose I became obsessed with it really but I just - I think, as I say, I was looking for other people to solve my problems for me rather than - no one actually suggested to me Mark that I should actually take part in the recovery process, I was still waiting for people to do things to me.
PORTER
So what changed and how are you now?
MOORE
What changed really for me was I just actually - I was doing lots of searching and making lots of phone calls, writing letters to pain patient groups that I got to know about and a lady up in Norfolk actually told me about the Input pain management programme at St. Thomas' and by then I'd actually started up a back pain support group in my area because I'd learnt from being involved with support groups that when you bring people together who share a common problem that you can perhaps swap a few ideas. And I got Amanda Williams, who's the clinical psychologist for the programme, to come along and do a talk to our group and in the talk she was actually describing me, you know, she said to me on good days you'll do more and on bad days you'll do less, you're probably not pacing your activities. And this is the sort of stuff I wanted to learn about. So I waited 18 months and I actually attended a programme in July '96 but it really turned my life around. They actually gave me the tool box of skills that I needed to self manage my pain in a more effective way.
PORTER
But how did going to a pain management programme actually change the way that you tackled your own discomfit?
MOORE
As I started to stretch and exercise and pace my daily activities I found that I could do more and my confidence started to increase. I wanted to help other people with similar problems and the time that I did have on my hands I actually sat down and wrote a self management programme for people specifically with back pain.
PORTER
And are you still in discomfit on a day-to-day basis, do you take any medication for your back at the moment?
MOORE
No, I haven't taken - in fact I haven't seen my GP now for eight or nine years about the back pain, I self manage my pain everyday, I stretch and exercise everyday. I know a lot of people disbelieve me but I even stretch and exercise on Christmas Day, my birthday because for me - I look at this way Mark that if someone's been diagnosed with diabetes they have to take their medication each day to keep functioning properly I guess, to keep healthy but for me my medication is pacing my activities, stretching and exercising daily, doing some relaxation and just really today I just really enjoy myself and enjoy my life, I don't really get - I know it sounds... In fact I was up in Middlesbrough yesterday giving a talk to pain healthcare professionals up there and the same question was asked of me - do you still get pain - and I said well not really no - but you've travelled all this way up here - I said - yeah but I pace my activities, I'm here, I don't really get pain anymore.
PORTER
Charles Pither was medical director of the Input programme that Pete attended.
PITHER
The problem with backs in a word I suppose is that we don't have a cure.
PORTER
He now runs a similar course at the Real Health Insititute in West London. Caroline Swinburne went along to find out what is involved.
PITHER
I mean if you have a hip that's getting increasingly painful you know that at the end of the day somebody can do a hip replacement operation and you've got a very good chance it's going to make you a lot better. But unfortunately that just isn't the case with backs and what we tend to do is to come up with ideas about what's wrong, so sometimes people get very firm messages - oh it's just the facet joint or it's just the L5 disc. In actual fact those people who are really in the know, the real experts, who are really honest, have to admit that very often we just can't tell that. And so in fact in some areas of back pain we back off from these very focused diagnoses and say no you've just got back pain.
JOHNSTON
My name's Caroline Johnston and I've been having serious hip and back pain for just over a year. On a bad day you really just want to curl up in a ball and turn all the lights out and just get away from the world completely. It can make you very sad, I mean I've had bouts of just bursting into tears for no reason, I'll just be sitting at home and I think I'm okay and then just burst into tears and it is really about the frustration of not being able to do small things.
ACTUALITY - REAL HEALTH INSTITUTE COURSE
If you're on a bad day it's managing to pace yourself - taking your time, taking little breaks so that you can manage to get through these numbers. And be aware as well of course that your borderline's been changed, so that ...
PITHER
What happens is we have a group programme, which has got perhaps 10 people on it, we have an interdisciplinary team so we have physiotherapist, psychologist, nurse, doctor, occupational therapist. We fill our patients' day, so they come on a programme which may be - it may just be a few days, as an outpatient, or it maybe - our longest course is over four weeks working on various areas. And the three big areas are physical fitness, practical techniques and strategies to help manage the pain and a range of psychological stuff from information through to relaxation training.
ACTUALITY - REAL HEALTH INSTITUTE COURSE
When you're feeling down the pain - you focus more on the pain, so the pain increases, so you feel worse, so you focus on it more. So there has to come a point where you just have to stop.
Because I'm a psychologist I don't want you to be thinking that I'm assessing you in any way in terms of whether the pain's made up or in your mind or even that you're going mad - we don't go down those lines.
DANIEL
My name's Claire Daniel, I'm a consultant clinical psychologist. The programme runs along a cognitive behavioural model and that looks at people's - the way people are thinking - their thoughts - looks at their behaviour, looks at their emotions and of course how the pain is involved in all of that. And we look at how those four elements are very much interlinked and how one affects the other and so the cycle continues.
PITHER
The first message we give is that back pain is not damage, pain is not damage, you are not damaging your back, your back may hurt a lot at the end of the day but there's no evidence that you've done more damage to it. And we've been looking at getting the patient to address some of their fears and the feared movements in the security, if you like, of the unit here. But also quite crucially tackling their fears, their beliefs and their stress.
JOHNSTON
I hate the exercise I really hate it. We've had a whole series of sessions on pacing, which is all about working out what activities you can do on a good day and a bad day and then coming up with a level of those activities to do every single day, regardless of how you're feeling. I actually have to be careful because I'm actually developing a fear of that bike, you know, because of the difficulty in doing that particular exercise.
ACTUALITY - RELAXATION CLASS
This is only day three, day four, I have still a degree of cynicism within myself as to is it going to work for me. And I - it's been a tough week - physically it's been a tough week and mentally it's been a tough week. I am optimistic of finding a way to manage the pain, to do things despite the pain but I think within myself I'm still looking for an answer as to what caused my pain, I'm not going to find that here and I have to deal with the fact that I'm not going to find that here because that is in a lot of ways stopping me from managing the pain.
PORTER
Caroline Johnston hoping for some relief from her back pain.
You are listening to Case Notes. I'm Dr Mark Porter and I'm discussing back pain with my guest Dr Steve Longworth.
Steve, how convincing is the clinical evidence that these sorts of pain management programmes actually have a really significant effect on things like the quality of life, the number of painkillers etc.?
LONGWORTH
There is good evidence. The problem, in my experience with most back pain programmes, is that there just simply aren't enough of them and that because they're few and far between people get sent to them late as a last resort and we see patients who've had their pain for 6 to 12 years referred to one of these programmes, they should really be being referred when they've had their pain for 6 to 12 weeks. And I think if we manage to do that then we have much better outcomes and I'm sure that the science would demonstrate that people did much better if they were seen early before they became established in the chronic pain role.
PORTER
Is there a move towards that, is there an acceptance amongst the "back pain industry", in inverted commas, that this is something we should be doing?
LONGWORTH
I think in theory there is, in practice we still seem to be doing the same old, same old and you'd be amazed by the number of people that get sent to the surgical spine clinic, where I work, who don't have a surgical problem. But that's because ...
PORTER
Well most don't presumably - most don't because surgery's only offered to a tiny minority of people with back pain isn't it.
LONGWORTH
It's something like 1 in 800 people with back pain will get an operation for it, so it's clearly not a surgical problem.
PORTER
And it must make economic sense to put people on a four week course or an eight week course or whatever if it stops them coming back to their doctor every three or four weeks and improve their quality of life.
LONGWORTH
It's difficult to understand why we still do what we do.
PORTER
Well let's go back to acute pain. Assuming the story reveals no alarm bells, those red flags that you discussed earlier, how should we be managing - we heard Peter earlier saying that lots of people still mistakenly believe that bed rest is the best thing.
LONGWORTH
Well there's certainly been a revolution in the way that we treat mechanical back pain over the last 25 years. When I qualified a quarter of a century ago we strapped people to the bed, as the management for their back pain, and told them not to get up. Now we know that rest actually makes you worse and it prolongs your recovery time. So it goes back to this business of giving people positive messages, it's hurting, it's not harming, the pain doesn't mean damage, avoiding the bed rest, getting moving as soon as possible. If you want the best advice for this I could thoroughly recommend a little booklet called The Back Book, which is published by the Stationery Office, it costs about 拢1.25 and it's a superb summary of all the things that you should do to help yourself to get going.
PORTER
But this activity includes an early return to work as well.
LONGWORTH
Absolutely and in fact the longer you're off work the more difficult it is to get back. If you're off work with back pain for six months you've only got a 50% chance of getting back to work. If you're off with your back pain for two years you've got less than one percent chance of getting back to work.
PORTER
What about manipulation - osteopaths, chiropractors, physios - does it help and does it make any difference which of those you see?
LONGWORTH
I'm a big fan of our hands on colleagues and I do a little bit of spinal manipulation myself. We think that the evidence about spinal manipulating - there is some evidence that it's a helpful thing to do and the same is true of acupuncture, as a treatment for back pain, so for chronic - not for the more acute short lived back pain but for longer back pain there is some evidence for acupuncture. But both manipulation and acupuncture I think have to be delivered in the context of this idea of activation. What we mustn't do is to make patients the passive recipients of pain, you lie there and I make you better. Certainly things like manipulation and acupuncture and other sorts of treatments can help to take the edge of the pain to get people going but that's the point - they must get going as well.
PORTER
And do you have any strong feelings about which - if they're going along the manipulative line - which type of practitioner they see or is it all much of a muchness?
LONGWORTH
I think when you look at what the final pushes that people do, the final manipulative manoeuvre, there's a lot of similarity between osteopaths, chiropractors, manipulative doctors and physiotherapists and I think it's as much to do with the skill of the individual as to whatever school of philosophy they're a part of. But I've got some excellent colleagues who do some fantastic things with patients to help them to get going and I think the ones who do the best are those who embed their manipulative techniques in this whole philosophy of let's get people active.
PORTER
So it's a holistic approach.
LONGWORTH
Absolutely.
PORTER
What about medication, I mean that's what we're dishing out in the surgeries, the GP, probably the only tool I have instantly to hand is to get rid of the pain, that alone does that help?
LONGWORTH
Some people find medication extremely helpful and I'm a big fan of combining this with other treatments. There are no hard and fast rules about it, you do what works for individual people to get them going.
PORTER
But covering that pain up using a strong anti-inflammatory or a strong conventional painkiller won't be harming the back at all?
LONGWORTH
This is a common misbelief that people think that they're masking the pain and therefore damaging themselves. Anything that gets you going and allows your muscles in the back to get moving, the joints to get moving, the back to strengthen up again that's got to be a good thing.
PORTER
What about sciatica, what's different about that from other causes of lower back pain?
LONGWORTH
Well sciatica's a slight misnomer. The sciatic nerve's actually in your buttock and sciatica's got nothing to do with your sciatic nerve. We use this term really to mean pain that comes from the nerves at the bottom of the spine, they're usually being squished a bit by a disc that's moved slightly. In fact your discs don't really move, what happens is your discs are a bit like a Jaffa cake and the squidgy bit from inside the Jaffa cake squirts out through the crispy bit and squashes against the nerve and this irritates the nerve and gives you pain and pins and needles that you feel down your leg and often as far as your foot and ankle.
PORTER
And this is what's often referred to as a slipped disc.
LONGWORTH
Slipped disc, absolutely yes.
PORTER
Most of which get better on their own.
LONGWORTH
It does indeed. Probably not quite as quick as mechanical back pain, something like 50% of people with an episode of sciatica will be better in about six weeks or so. For people who are getting better much more slowly, let's say you've still got your symptoms at three months, it's at that stage that we start thinking about do we need a scan, do we possibly need to be thinking about giving you an injection around the nerve root that's being irritated. Some people will have a very large disc prolapse that doesn't get better with the treatments and will occasionally need surgery and that's often extremely successful at relieving their symptoms.
PORTER
Well Michael Grevitt is a consultant spinal surgeon at the Queen's Medical Centre in Nottingham and just the sort of person that someone with persistent sciatica might end up seeing.
GREVITT
These days with MRI scans we can actually localise the [indistinct words]. I would say that surgery in these instances is far less invasive than it is and in fact there has been a trend over the years to actually minimise the incision and the use of microscopes and sometimes in rare specialist centres the use of endoscopes to visualise the actual disc and just minimise the amount of surgical trauma related to what was hitherto a much larger and much more disabling procedure.
PORTER
How do select somebody for surgery who's got troublesome sciatica as a result of a disc problem, from those who are going to get better on their own, is it just simply a matter of time?
GREVITT
Yes and what one has to understand is that 90% of patients who present with sciatica in general practice will get better on their own and other than just requiring support with analgesia and perhaps physiotherapy, they in fact never get to see a spinal surgeon. So what people like myself deal with are rather the 10% who do not settle within the requisite three months and who have significant disability.
PORTER
What about the newer techniques that don't actually involve the surgical knife?
GREVITT
Yes these are now sort of being investigated increasingly by those with a significant spinal practice and names such as intradiscal thermal treatment, nucleolysis etc. are applied to techniques whereby putting needles into the disc, under local anaesthetic, and passing various needles and catheters and wires down those needles allows application of heat or radio frequency energy to so call shrink discs, to thereby relieve the pressure on the nerve that previously was only accessible by open surgery, the microscope and a surgeon's knife. So these are techniques that are being investigated but I would emphasise that they are at present under clinical review and not part of the sort of mainstream armament of a spinal surgeon.
PORTER
Michael Grevitt. Liann from North London had persistent sciatica which started during pregnancy. She had surgery on her back earlier this month in the hope that she could be pain free for her next pregnancy.
LIANN
I had the surgery on - scheduled for the 3rd January. I came out of hospital six days later, which I was absolutely amazed, I thought I'd have pain for weeks and I thought I'd need walking sticks and I thought I wouldn't be able to move. My surgeon was really happy with my recovery and if anyone is bent on surgery - and I don't know the long term yet because obviously it's too early to tell - but if anyone is scared of the fact of actually having the operation I would say don't be because I'm the biggest wimp going. I went back two days later and had the staples out, which I thought would be a real trauma, and it wasn't at all. And now I'm just really sort of trying to take it easy but the wound pain is - each day there's a marked difference. I have still, from time to time, got slight referred pain, so very dull sciatica. If I take it back to when the sciatica was at its peak and it was a 10, it's probably a 2 - it's completely manageable. I mean obviously surgery's not going to be relevant to everyone or the right choice for everyone but for me it definitely was and I'm just hoping that it's worked really.
PORTER
Liann recuperating at home.
Steve, how successful is that sort of disc surgery in general?
LONGWORTH
In the clinic where I see patients the vast majority of people who have disc surgery for sciatica either have a complete cure or a substantial improvement in their symptoms.
PORTER
Steve, we haven't talked much about prevention, obviously good posture, lifting sensibly can help prevent problems but what about exercises, is there any evidence that people prone to back problems, for instance, can benefit from exercises designed to strengthen their core stability, a bit of a buzz word at the moment?
LONGWORTH
It is and reassuredly the current best evidence is that simply being aerobically fit is as good as doing fancy work in gyms with specialists. One of the best trials - what they did was to take people and they either had some special exercises to strengthen their backs upon special machines or went to see the physios and did all the core stability work or went and jogged in an aerobics class and at the end of this trial all three groups were doing equally well. And in fact in the long run the people that went down the aerobics class actually did the best. And I think this is about being non-medicalised, having fun, doing something that you're likely to stick with and I like to think we can normalise the whole concept of back pain and see it as part of the shocks to which [indistinct words], rather than being the medical disaster it has been in the 20th Century.
PORTER
And presumably people who are doing exercise that they enjoy are more likely to continue it and that's key as well isn't it.
LONGWORTH
Absolutely.
PORTER
There's no point in doing something for six weeks if you're going to give it up.
LONGWORTH
If you're aerobically fit and you're not overweight you're far less likely to get back pain.
PORTER
We should just say what we mean by core stability - that's exercises of the abdominals, back and pelvic floor isn't it.
LONGWORTH
Yeah, this is the six pack type exercises to strengthen your tummy muscles.
PORTER
Well we're almost out of time but perhaps we should finish with a reminder of those lists of red flags - the signs and symptoms that ring alarm bells in doctors when seeing people with back pain.
LONGWORTH
These would be things like your pain starting under the age of 20 or over the age of 55 - that's your first episode; violent trauma; pain that's constant, progressive, keeping you awake and not responding to simple painkillers; a past history of cancer or if you're generally unwell with fever and weight loss. There are some others.
PORTER
But ending on a lighter note - the vast majority of people that I see, certainly as a GP, and probably even the ones that you see in the clinic, don't need - don't have anything particularly sinister going on.
LONGWORTH
Absolutely.
PORTER
Dr Steve Longworth, thank you very much.
And thank you for all your letters and e-mails on the subject - I hope we have addressed most of your queries.
You can get further details on the pain management programme, and other useful contact details by calling the action line, that's 0800 044 044, or by visiting our website at bbc.co.uk/radio4.
Next week I'll be exploring a rather different area of medicine. At the end of last year surgeons in France performed the world's first face transplant on a woman after she had her nose and chin chewed off by her dog. I'll be visiting one of the UK's leading centres to learn more about the physical and psychological challenges facing both surgeon and patient when it comes to tackling facial deformity.
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