If you are too tall for washing up without stooping over the sink, raise the washing-up bowl by putting it on a small wooden stand, or on top of another upturned bowl, or on the draining board. If the surface is too high for you, try standing on a small step (made out of an inverted box, perhaps) while working there, but you could hurt yourself by forgetting about the box and stepping off unwittingly.

Ideally, it would be better to rearrange your kitchen so that the worktops are the correct height. The top of a sink should be at about elbow height, but work surfaces and the top of a cooker should be two or three inches lower. It is important to stand close to the work surface.

Less standing-You may be able to cut down on cooking: by the use of a microwave oven and a freezer, you can abolish lengthy standing at a conventional hob, do away with heavy metal saucepans, reduce washing up. Having a reserve of frozen dishes means that there can be a hot meal even when your back is playing you up: but be sure to have an upright freezer, not the cavernous chest type.

Many domestic activities (preparing food, washing up, ironing) can be done seated. There is no law that says you have to stand to iron. Alter the height of the board to relate to your sitting position. It is important not to have it too high because having the arms continually raised imposes strain on the shoulders, neck and upper back.

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A Shiatsu session can be expected to last between 45 minutes and an hour and a quarter. The first session usually begins with a history-taking and diagnosis, following a similar pattern to acupuncture. Treatment will be given by exerting pressure on several specific points, as well as general kneading massage. Pressure is applied in a great variety of ways. Sometimes the thumb or fingers are used, sometimes the palm or heel of the hand, or a knee or elbow. The intensity of pressure varies between gentle massage to a very strong pressure, but no more pain should be felt than that involved in the release of tension. Some Shiatsu practitioners also use osteopathic and chiropractic techniques, based on energy movement.

Shiatsu can be used for the treatment of specific problems (including back pain), and also as a general preventive health measure.

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Most surgeons insist on some such investigation before deciding whether to recommend an operation. Some of these tests may require you to be admitted to hospital for a couple of days.

Myelography or radiculography-This is a method of making the dural tube show up in X-rays, by injecting a contrast medium – a radio-opaque liquid – into the cerebrospinal fluid around the spinal cord. This is done under local anaesthesia, by lumbar puncture, the

needle being inserted through the skin of the back between a pair of vertebrae at the appropriate level. It is not a pleasant experience and is usually only recommended if surgery is thought likely.

Using an image-intensifying screen, the radiologist can see whether the spinal canal is abnormally narrow and whether anything is obstructing it – such as the bulge of a prolapsed disc, or a degenerated joint. These show up as an indentation on the dural tube, or an obliteration of part of a dural root sleeve. In rare cases, back pain may be caused by a tumour on the spinal cord, and this, too, would be shown up by myelography. As a matter of routine, a sample of the cerebrospinal fluid is taken for laboratory testing.

The lumbar puncture is done while you lie on a table which can be raised to the vertical, so that the radiologist can observe the movement of the contrast medium in the dural tube as you are tilted up and down. The table may also tilt sideways, or the apparatus rotate in relation to the table, so that the radiologist can view the spine from different angles. He will probably take still radiographs to record the significant findings. Most of the time, however, he will be studying the picture on a television monitor which you may be able to see, too.

When the myelography is finished, you may be sent to a ward, with instructions to rest quietly for up to 24 hours and may be warned of the possibility of getting severe headache or nausea for a while, as an after-effect. Myelography is, to say the least, uncomfortable. Nowadays, a

water-based contrast medium is used. This is soon eliminated by the body, and does not usually cause irritation in the tissues of the spine.

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To some extent, degenerative change can produce similar effects locally in individual joints. A completely degenerated intervertebral joint – disc, ligaments and joint facets – is stiff, fibrous, and narrow.

Degenerative change can -start in one’s teens, but the likelihood of it increases with age. It differs from the ageing process, however, in that ageing affects the spine as a whole, while degeneration generally begins in a single intervertebral segment. There may be advanced degenerative change in just one site, with apparently normal discs and joints above and below it.

Degeneration may begin in the disc itself, or in the joints or ligaments – particularly the interspinous ligaments which join the vertebrae.

Degenerative change tends to begin much earlier in people who do heavy unskilled manual labour. It can also start early in people who go in for strenuous forms of exercise – but some experienced weight-lifters show no more degenerative change than sedentary workers. It seems that violent exertions and unskilled efforts are most likely to cause minor damage to the cartilage between discs and vertebral bodies, or to the ligaments. If they are repeated often, there is a cumulative effect leading to degeneration, even though at the time each injury felt no worse than a momentary jarring. There is also some evidence that prolonged awkward posture may lead to such damage.

Back pain and degeneration do not invariably go together; they do not necessarily bear any relationship to each other. Plenty of people undergo major degenerative changes in their spine without ever suffering from back pain.

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