Archive for July 2015

Focus on: Acute low back pain

low back pain1Low back pain is a very common problem.  Studies estimate that 80-90% of people will experience back pain at some point in their lives, and at any point in time about 25% of all adults in Australia will have back pain. (I should point out at this point that “low back pain” is a massive topic that would take many thousands of words to cover – so this article will focus on acute low back pain).

Acute low back pain refers to a sudden or recent onset of low back pain.  In medical terms acute = recent. It does not necessarily mean severe. (While we’re at it, the term chronic = long term or persistent – usually greater than 3 months duration). As you saw it is an extremely common problem, so chances are you, or someone you know, will have experienced this sudden or recent onset of low back pain.

In most cases, acute low back pain is quite simple, and represents a simple back ‘strain’  associated with a mechanical loading incident or a ‘pain flare’ associated with psychosocial or lifestyle stresses (more on that later).  Only 1-2% of people who suffer an acute episode of low back pain will have any serious injury or illness.

Lower-Back-Pain-Right-Side2Despite this, low back pain has a very bad reputation, and there are a lot of misconceptions and misinformation about your prognosis and the injury itself.  So the following is some information to dispel some myths and fears, as well as some excellent advice as to what you should and shouldn’t do if you have low back pain.

In about 90% of cases, low back pain is a simple mechanical issue (a sprain or strain). It is really no different to pulling a hamstring or rolling your ankle.  Studies show that about 80% of low back pain incidents will resolve with about 6-8 weeks.  Of the ones that don’t, 80% of those will resolve within 6 months – so by and large almost everyone will get better from low back pain.  This is important to remember as I hear in the clinic all the time people saying things like “I know if you hurt your back it will never get completely better”.  We know from the evidence that this is just not true.  For some reason, we seem to think about hurting our back differently from other body parts.  Almost everyone has suffered some kid of musculoskeletal injury in their lives (a sprained ankle at netball or a pulled muscle) and we know those all got better, so why would we think the back is any different?

So now that we know that your back pain is highly likely to get better, what can you do to help it get better quicker? And what shouldn’t you do to slow your recovery? Let’s start with the DON’TS:

DON’T

Don’t Freak out

So you were lifting in the gym, or gardening, or picking up your socks, etc. and you’ve felt a sudden “twinge/pop/twang/etc” in your back. This is what we referred to as a mechanical loading incident.  Already your mind starts racing with fear and anxiety:

“OMG I’ve stuffed my back!”

“I’m not going to be able to do that Crossfit competition! What if I can never do Crossfit ever again?”

“What if it’s broken? I might be paralysed!”

“What if my back is ruined forever? How am I going to support my family/pay the mortgage?”

And it goes on and on.  To a point this is normal psychology, but you need to remember that your mind is racing to worst case scenarios. This anxiety and fear is just going to make things worse (and there is strong evidence that fear, anxiety and negative beliefs have a negative impact on recovery).  If you honestly believe you’ve ruined your back, it’s going to take a long time to convince you otherwise, regardless of the actual injury.  Negative emotions – fear, anxiety etc. have been shown to worsen your experience of pain as well. So now you know that none of these thoughts are actually true, calm down and approach your injury pragmatically.

Don’t Rush to get an x-ray/CT/MRI

In most cases, imaging such as this is not beneficial – many low back pain cases are “non-specific” meaning we are unable to identify exactly what the painful structure is (especially on imaging).  This also has nothing to do with how bad your pain is – just because you may have high pain levels does not mean you are more likely to need a scan.  There are specific cases that do indicate that a scan should be performed, and your physiotherapist (or well-trained GP or other health practitioner) will be able to identify whether it is necessary.  These include significant, persisting or worsening neurological deficit (significant pins and needles/tingling/numbness, significant weakness, bladder or bowel dysfunction, numbness in your crotch/perineal region – also known as saddle paraesthesia) or indicators of serious pathology or injury (such as fracture, infection, tumour).  As you now know – these are quite rare.

In the majority of acute low back pain imaging is not required, but we do see a lot of over-imaging in health care from well-meaning health care professionals.

lumbarmriAnother reason not to have imaging is that it has been shown that many people who have never had back pain will have “abnormal” findings on scans.  (91% for disc ‘degeneration’, 56% for ‘disc bulges’ 32% for ‘disc protrusion’).  So there is no correlation between “abnormal” findings on your scan and any pain you actually have.  Chances are those findings would have been there long before you had pain – and were causing you no problems whatsoever.  Many of these changes are normal responses your body has to everyday life.  Like wrinkles on your skin, or grey hairs, these changes in the appearance of your back have no impact on how you feel or how it functions.

Finally, having a scan early on after your incident has been proven to actually slow down recovery and increase total costs. Partly this is because of all those incidental findings I just mentioned, and how this is explained to patients.  If a well-meaning health professional didn’t understand that these findings are normal, and then told you how there was all this “damage” in your back – your fear/anxiety levels would go up, and the way you behave to manage your back would change.

So now we know that imaging is largely unnecessary, unless there are specific issues that we identify from your assessment. These are quite rare.

Don’t Listen to the haters

My Momma hurt her back and now we have to roll her out of bed with a stick

My Momma hurt her back and now we have to roll her out of bed with a stick

Everyone seems to have a story about how their 2nd cousin’s wife’s gardener hurt his back and now he’s in a wheelchair/had to have surgery/ couldn’t work ever again.  For some reason

people love to tell you bad stories about how you’ll never get better.  (Reverse tall poppy syndrome perhaps?) If you venture onto the internet for answers, no doubt you’ll find even more

information to back up this negative outlook.  Remember that numbers don’t lie – by and large everyone recovers from low back pain, no matter what cousin Cletus says. Also remember that Dr Google is almost never right.  I can count the number of times on ONE HAND that a patient has come in with a printout from the internet and was actually right about their injury.

Don’t do Bed rest

A long time ago, you used to be told to go to bed and rest if something was wrong with you.  In terms of low back pain, this is a terrible idea.  All studies show that staying active is far superior to resting for low back pain recovery (more on this below).  Inactivity makes you stiff and weak – both of which are risk factors for more low back pain.  Normal recovery requires normal load and normal movement (termed mechanotherapy – it drives a lot of what we do in physiotherapy).

Now you know what NOT to do, what will help your recovery and get you back to full activity faster?

DO’s

Stay Active

All studies show that staying active is a highly effective method of management for acute low back pain.  I can’t stress this enough that trying to maintain normal activity will significantly help with your pain and speed up your recovery.  Conversely, avoiding movement or being over protective can actually increase your pain and prolong you pain.

If you’ve ever attended physiotherapy for low back pain you should have left with a good understanding of this, as well as some specific advice regarding activity and ‘exercises’ that will help.  While different presentation may benefit from different types of activity better – it is usually safe to recommend some walking, activity in the pool and gentle low back mobility exercises (such as rotation and extension)

MINOLTA DIGITAL CAMERA                                                         MINOLTA DIGITAL CAMERA

Check Your Beliefs

Like I said, low back pain has a bad reputation.  Many people seem to think that a back injury is a lifelong affliction.  Injury to your back really is no different to any other injury – And we see far less people thinking their calf strain will be there forever.  Your body is an incredible self-healing machine, and by and large you will recover!

People also seem to think that the low back is a weak area of the body – and structurally this is not true at all.  There is quite a lot of muscle, ligament and connective tissue that protects and supports this area. Now there are a lot of important structures within your spine (like your spinal cord) so your body is well designed to protect this area.  Because of these important structures, your brain and body are quite sensitive to warning signals (pain) coming from this area – so your brain will often create quite a lot of pain when an issue arises in the low back.  So just because you might have a lot of pain doesn’t even mean you have a lot of injury.

It’s important to understand that hurt ≠ harm.  This means that you can have pain without any actual damage or injury at all.  Pain is a warning or danger system that your brain has to alert you that there is something to be aware of.  Think of times that something hurts but there is no damage done.  When you touch something hot – it hurts and you automatically pull your hand away.  Then when you check your hand there is no burn – the pain just warned you that injury might happen. When you bend you finger back too far (or someone gave you a Chinese burn at school) it hurt because the tension on the tissues reached a certain point that it produced a noxious stimulus. Your brain then interpreted that and told you there is pain, but no harm is done at all.

How you approach you r injury and recovery has a significant impact on how you progress.  Stay positive in the knowledge you have gained here and focus on the process you have to go through.  Recovery takes time, so you may need to be patient.

Get Assessed!

Injuries can be stressful and confusing (as well as painful).  Knowing what to do is half the battle. Little twinges usually go away on their own within a few days (particularly if you follow the above advice).  If the pain is persisting, limiting your ability to do things, means you are missing work or other activities you want to participate in or causing distress – then come and get assessed by a qualified professional who can properly diagnose and treat your problem.

All the clinicians at EMC Physiotherapy are highly qualified and experienced primary contact practitioners.  We can identify if you fall into those less common categories that might require further investigation or referral. We can also provide you with best practice, evidence based advice and treatment based on specific injury to get you back to doing what you love faster.

Now as I said, the large majority of low back pain will resolve on its own within 6-12 weeks.  Studies have shown, however, that physiotherapy treatment results in faster recovery from injury overall. So while there are similar results at 12 week, physiotherapy treatment results are superior at 2 weeks, 4 weeks and 6 weeks.

Recent studies have also shown that early attendance to physiotherapy treatment (within the first two weeks of onset of pain) also resulted in significant cost savings for treatment when compared to later attendance.  This means that the sooner you commence treatment, the cheaper it will be overall.  We do often find in clinical practice that many people wait for 4 or 6 weeks before they attend for treatment, and by that stage they have developed more chronic problems and lots of secondary compensations that also need to be addressed.  This then requires more treatment and a longer recovery time.  I often think that if we had seen those people quickly after their injury, they would have been recovered by 2-4 weeks post injury and back to work/sport etc. before the time they even first attended the clinic.

Take Home Messages:

1. Acute low back pain is very common and by and large most people will fully recover within 6-12 weeks.

2. Usually imaging (such as x-ray, CT or MRI) is not necessary, and may actually lead to slower recovery. Many of the findings on scans are considered ‘normal’ even if they sound bad.

3. Understand that what you are experiencing is quite normal. Try to avoid unhelpful beliefs and behaviours that will slow down your recovery.

4. STAY ACTIVE! This is the most important piece of advice I can give you.

5. Get Assessed.  Early access to appropriate diagnosis, education and management leads to faster recovery and reduced overall costs.

 

Stay tuned for an upcoming article on treatment and rehabilitation of low back injuries. As always please feel free to get in contact with us with any queries regarding anything at all.  We are always happy to hear from you.

 

Julian Bowen

Julian is the owner and Principal Physiotherapist at EMC Physiotherapy in Ellenbrook.  He has spent  over a decade working exclusively in private physiotherapy practice, and estimates he would have performed over 35,000 individual treatments in that time. He has worked with everyone from Paralympians,  elite athletes, WAFL Footballers, the Defence Forces and weekend warriors, to thousands of everyday people with all manner of issues.  He is passionate about injury prevention and has a special interest in the treatment of headaches, shoulder issues, hypermobility management and exercise rehabilitation for the prevention and treatment of injuries. 

 

 

References:

Fritz, JM, et al (2015) Physical Therapy or Advanced Imaging as First Management Strategy Following a New Consultation for Low Back Pain in Primary Care: Associations with Future Health Care Utilization and Charges. Health Services Research; doi: 10.1111/1475-6773.12301

O’Sullivan, P & Lim I (2014) Acute Low back pain: Beyond Drug Therapies. Pain Management Today; 1(1): 8-13

Walker BF (1999) The prevalence of low back pain in Australian adults. A systematic review of the literature from 1966-1998. Asia Pac Public Health; 11: 45-51

. Deyo RA. (2013) Real help and red herrings in spinal imaging. New England Journal of Medicine; 368: 1056-1058

McCullough BJ, Johnson GR, Brook MI, Jarvik JG (2012) Lumbar MR imaging and reporting epidemiology: do epidemiologic data in reports affect clinical management? Radiology; 262: 941-946.

Main CJ, Foster N, Buchbinder R (2010) How important are back pain beliefs and expectations for satisfactory recovery from back pain?Best Pract Res Clin Rheumatol; 24: 205-217

Darlow B, Dowell A, Baxter GD, Mathieson F, Perry M, Dean S (2013) The enduring impact of what clinicians say to people with low back pain. Ann Fam Med; 11: 527-534

Gatchel RJ, Peng YB, Peters ML, Fuchs PN, Turk DC (2007) The biopsychosocial approach to chronic pain: scientific advances and future directions. Psychol Bull; 133: 581-624

Chou R, Deyo RA, Jarvik JG. (2012) Appropriate use of lumbar imaging for evaluation of low back pain. Radiol Clin North Am; 50: 569-585

Haldeman S, Kopansky-Giles D, Hurwitz EL, et al. (2012) Advancements in the management of spine disorders. Best Prac Res Clin Rheumatol; 26: 263-280

Henschke N, Maher CG, Refshauge KM, et al. (2008) Prognosis in patients with recent onset low back pain in Australian primary care: inception cohort study. BMJ; 337:a171

van Tulder M, Becker A, Bekkering T, et al. (2006) Chapter 3. European guidelines for the management of acute nonspecific low back pain in primary care. Eur Spine J; 15(Suppl 2):S169–91

Henschke N, Maher CG, Refshauge KM, et al. (2009) Prevalence of and screening for serious spinal pathology in patients presenting to primary care settings with acute low back pain. Arthritis Rheum; 60:3072–80

Childs et al. (2015) Implications of early and guideline adherent physical therapy for low back pain on utilization and costs BMC Health Services Research; 15:150

Gellhorn, et al. (2012) Management Patterns in Acute Low Back Pain: the Role of Physical Therapy Spine; 37(9): 775–782

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The Stretching Debate: What does the evidence say?

 

There’s been a bit of a backlash against stretching within the fitness industry over the last few years – some even going as far as to say that stretching is bad for you and you shouldn’t do it.  A lot of this opinion is loosely based on recent research regarding stretching prior to exercise and injury prevention, but is it actually bad for you? Or does it actually prevent injury like your  under 13’s footy coach told you?

Well the short answer  is no…… and yes….. (you’ll see what I mean a little later)

Back in the day, you would go to footy or netball training and your warm-up would be two laps around the oval and 10 minutes of static stretching before you start training or playing.  (Static stretching being where you sit, lie or stand and hold stretches for 20-30 seconds each). This was to make sure you “warmed up properly” and “don’t hurt yourself.”  There is a lot of research now to show that this type of static stretching prior to exercise does not reduce your injury risk, including several big systematic reviews (a high level of scientific evidence) that all show that static stretching as part of warm up does not reduce you risk of injury.

So does this mean that stretching is bad for you? Well no, no it doesn’t.  If we look at the evidence it found that there was no difference in the risk of injury between the stretching groups and the non-stretching groups. This means that stretching as part of warm up does not increase your risk of injury either. Some people in the fitness industry have taken this research and declared that stretching is bad for you, but looking at this evidence we know that actually it’s not.  Having said that – based on the evidence we wouldn’t recommend static stretching as part of your warm up normally.

But wait, there’s more!

Static Stretching has also been shown to reduce peak power and force output in the muscle stretched.  This is often referred to as  acute stretch-induced strength loss. What this means is that after static stretching, your muscle is not able to produce quite as much force (strength) as it could prior to stretching. As we know that reduced strength is a risk factor for soft tissue injury, again some proponents are up in arms against stretching. Also when playing sport why would we want to reduce our power output? It would only impair performance.

In reality this effect has been shown to only last for a few minutes, so whether this is likely to increase your risk of injury really depends on when you stretch and what you are doing afterwards.  If you are an Olympic weightlifter, it would not be wise to perform heavy static stretching within say 15 or 30 minutes of competing or performing maximal lifts.  Not necessarily because it will increase your risk of injury, but because it could reduce your performance somewhat (and the numbers quoted are often between 2% and 7% reduced strength – not exactly severe weakness). Interestingly, studies show that while peak power output is reduced immediately after stretching, a long term program of stretching does not reduce strength or power overall (provided you don’t test it immediately after stretching). So stretching yesterday will have no impact on your strength or power today.

So when we think back to those days of footy training, that warm up protocol really doesn’t assist in warming us up, and doesn’t reduce injury risk.  Therefore, the current best practice recommendation for warm up prior to exercise would be to NOT perform static stretches, but instead perform dynamic warm up designed to prepare your body for the exercise to come.  This should include things like large amplitude, controlled dynamic movements (such as leg swings), activities to gradually increase blood flow to the areas needed for exercise and activation/preparatory movements relevant to the activity. For example if you are playing basketball and likely to be doing a lot of jumping, warming up should probably include some loaded leg activities such as squats and lunges.  Maybe even practice some light jumping and landing before you hit the court and jump as hard as you can. If you’re a baseball pitcher – you probably should perform specific shoulder warm up.  As with everything in life – preparation is key.

Olympic gold medalist Mo Farrah can’t believe he wasted all this time doing static stretches for warm up. (source – The Guardian)

The other issue with this “old school” warm up is that when you stay still and perform static stretching after your two laps around the oval, you are actually cooling down. After raising your core temperature and increasing blood flow to the muscles and areas we need it to exercise by jogging, we are then doing the opposite by sitting down and stretching. So again, no to static stretching as part of warm up. (Do you see a theme here?)

So does this mean we should never stretch for warm up?

Well no, not always. I always say if you have something that you feel needs stretching before you exercise (like that old dodgy hamstring) and it makes you feel better (or more prepared to exercise) to stretch it – then by all means stretch it.  As we know, research shows it doesn’t really increase your risk of injury either. But make sure you include mostly active/dynamic warm up as well, and don’t do it immediately before really heavy deadlifts.

So what about injury prevention?

Now we also know from the research that a lack of mobility can be a risk factor for injury (depending on what you are doing).  A long distance runner, for example, only moves through a limited range of movement in specific directions. So their requirement for mobility/flexibility is less. An Olympic gymnast has very high requirements for mobility/flexibility – so they would need much higher levels of mobility to be considered not at risk.

Stretching at other times (NOT during warm up) does have some evidence to support a reduction in muscle and tendon injury risk.  There is also evidence to suggest that stretching after exercises can reduce the severity of muscle soreness.

In the real world, however, it should all come down to what your problem is and what you are trying to change. (We would call this specificity and it’s one of the most important considerations when designing rehabilitation, treatment and conditioning/training programs):

If you have impaired mobility/flexibility, and the sports/work tasks you perform require greater levels of mobility – then you should perform flexibility training to improve.  The same way that if you want to get better at running, you need to train running.  If you want to get stronger – you need to do strength training.  If you want to be more flexible/have better mobility – you need to do mobility training.

Here’s a picture of a cat stretching – you’ve come this far you deserve it.

In clinical practice – if your lack of flexibility or mobility is assessed and deemed to be contributing to your problems – then we would provide you with specific intervention to address this.

Now static stretching is just one type of mobility intervention.  Other popular types include PNF stretching (so hot right now), where we use muscle contraction and relaxation to affect muscle lengthening, joint mobilization, ballistic stretches (not always recommended) and even recently a study has been published showing that self myofascial release (foam roller, spiky ball etc) is effective in improving mobility/flexibility.

*A quick note on feeling the need to stretch:  Muscles that feel “tight” are not always the ones that need stretching.  Short muscles usually require flexibility training.  Tight muscles are often weak muscles or overworked muscles (if we ignore post-exercise soreness). Persistently stretching them may lead to increased fatigue (due to reduced peak power output) and lead to more “tightness” feelings. Strengthening “tight” muscles is often a very effective intervention to relieve that persistent tension feeling.  Every week I see someone who “carries too much tension in their shoulders – and they stretch and stretch and it just won’t loosen up”.  This is an excellent example of muscles that are likely overworked or lack endurance. Stretching is not likely to provide any long term resolution for this problem.

Modern concepts in stretching

There have been recent advances in our understand of how stretching and flexibility works.  Traditionally we would think of our muscles like a rubber band that could be loosened or stretched with mechanical stretching.  We now know that the nervous system controls our flexibility much more than we thought.  Part of the limits of our flexibility is how much our nerves “put the brakes on” to protect our tissues from damage by excessive length or tension.  This is part of our “danger” mechanism.  There are receptors in our muscle spindles (muscle cells) and golgi tendon organs (stretch receptors in our tendons) that provide feedback to the nervous system and constantly drive a certain amount of tension that resists excessive length in the muscles.  Remember your muscles do not do anything by themselves – they need the brain and the nerves to tell them what to do.  When people are under general anaesthetic (and their neural drive is turned right down) – suddenly they have excellent flexibility! Stretching is now thought to inhibit that neural drive, or modulate the “danger” response.  Passive stretching also seems to reduce peak power output because it inhibits the neural drive to the muscles.

Upper limb neural mobilization

Nerve tissue itself is also sensitive to excessive tension, and will drive muscle contraction/tension to protect it from excessive tension.  This means that “muscles protect nerves”.  With this in mind, we can also affect limited mobility and pain by modifying neurodynamics. Mobility or neural desensitization treatments/exercises can also improve mobility and reduce pain/tightness.  You know that tightness you feel in your calves or behind your knees when you touch your toes – that’s neurodynamic restriction in action!

Take Home Messages

  1. Static stretching prior to exercises does not reduce your risk of injury. Therefore performing these stretches as part of your warm up is not recommended.  Perform a dynamic warm up that adequately prepares your body for the task at hand.
  2. However, flexibility and mobility training is actually very good for you – if you have a restriction in flexibility. It can reduce post exercise soreness and reduce injury risk if you do not have the requisite flexibility to perform the required movements of our sport, or it is contributing to your symptoms. Perform targeted, specific flexibility training if you want to improve your flexibility.
  3. Tight feeling muscles may not need stretching.  Short muscles may need to improve flexibility, but tight muscles may be overworked, fatigue or weak. This particularly goes for postural muscles.
  4. The nervous system appears to be the primary driving force behind flexibility (or lack of).  The nervous system protects the body from injury/danger by resisting excessive muscle length.  Stretching can desensitize this protection mechanism, and teaches the nervous system that this new length is comfortable and not dangerous.
  5. Neurodynamic treatments and mobilizations can have a profound effect on your mobility and symptoms.

 

Hopefully this has enlightened you in ways to make a  difference to your life and to help you understand why your body works the way it does.  If you are having any issues with mobility, function or pain we are always here to help. Please feel free to get in contact with us with any queries regarding this or anything else.  We are always happy to hear from you.

 

Julian Bowen

 

Julian is the owner and Principal Physiotherapist at EMC Physiotherapy.  He has spent  over a decade working exclusively in private physiotherapy practice, and estimates he would have performed over 35,000 individual treatments in that time. He has worked with everyone from Paralympians,  elite athletes, WAFL Footballers, the Defence Forces and weekend warriors, to thousands of everyday people with all manner of issues.  He is passionate about injury prevention and has a special interest in the treatment of headaches, shoulder issues, hypermobility management and exercise rehabilitation for the prevention and treatment of injuries. 

 

 References:

  1. Small, et al. (2008). A systematic review into the efficacy of static stretching as part of a warm-up for the prevention of exercise-related injury.Research in Sports Medicine, 16(3), 213-231.
  2. Lauersen, et al. (2014). The effectiveness of exercise interventions to prevent sports injuries: a systematic review and meta-analysis of randomised controlled trials. British Journal of Sports Medicine, 48(11), 871-877
  3. Konrad & Tilp, (2014). Increased range of motion after static stretching is not due to changes in muscle and tendon structures. Clinical Biomechanics, 29(6), 636-642
  4. Schroeder et al., (2015) Is self myofascial release an effective pre-exercise and recovery strategy? A literature review.
     Curr Sport Med Rep 14,  200-208
  5. McHugh & Cosgrave, (2010). To stretch or not to stretch: the role of stretching in injury prevention and performance. Scandinavian Journal of Medicine & Science in Sports, 20(2), 169-181.
  6. Amako M, Oda T, Masuoka K, et al. (2003) Effect of static stretching on prevention of injuries for military recruits. Mil Med. ;168:442-446
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