Knowledge Is Power – What I Need People With Back Pain To Know

Here is some information I would like anyone with back pain to know. Whether it is the first time you have had back pain or you have had it for ages.

I would love others to contribute to building up this information as it is certainly not definitive. So if you are a clinician or have had back pain please email me if you have something to add ben@cor-kinetic.com

This has also been turned into a downloadable PDF so you can share with colleagues, patients or anyone you feel it may help. Please click Back Pain Share Pdf to get it!

Back Pain Information

  • Back pain is normal. Up to 20% of people are likely to get some each year and a whopping 80% of us will get some back pain in our lifetime, in fact, it would abnormal not to get back pain.
  • Back pain can last up to 6 weeks – this may be longer than you anticipated. So if it has been going on for a bit there is no need to unduly worry. Lots of pains only last a number of days but it is still normal for it to last longer.
  • Although we all know someone who has had long term persisting back pain that has caused lots of problems it is actually somewhere between 10% and 25% of people with back pain that lasts longer than normal. So you have good odds it won’t last longer than 6 weeks.
  • Back pain is no different to any other pain in our bodies such as shoulder, ankle or knee pain although people do tend to worry more about it.
  • Pain itself is normal and nothing to be scared of. It is a protective mechanism that has evolved to help us out. You would not want to live without it!
  • Pain is not good at reflecting the physical state of our back or any body part. We can have lots of pain without significant damage. Think about getting a paper cut or a bee sting. They can hurt like hell but don’t really damage us.

Diagnosis

Diagnosis can often be challenging with back pain although I know that people often want an answer. We don’t always need a definitive answer to help you.

Here is what we do know:

  • The vast majority of back pain is not serious, in fact around 99%. The 1% is mostly fractures, can include cancer, but these a pretty rare occurrences.
  • Around 10% can be pinned down to a specific tissue diagnosis such as a disc or a nerve.
  • These statistics mean that it is unlikely to be a ‘slipped disc’ or a nerve problem and people often throw these terms around as causes without really knowing this for sure. This can often be unhelpful.
  • Therapists have some tests to tell if the problem is in that 10%. These include clinical tests for the nerves and nerve roots as well as muscle strength, sensation and reflex tests.
  • It is very difficult to make a diagnosis from an MRI alone. Lots of MRI findings also exist in people without pain, hence the need for a clinical exam to accompany a scan.
  • MRI’s are not able to show us pain.
  • So we often can’t pin it down to a specific tissue or pathology around 9 out of 10 times. There are lots of different tissues in a small space and if it is irritated or inflamed then it may affect more than one of the tissues.
  • Inflammation is a good thing. It means the body is working well and doing its repair jobs.
  • From a medical perspective, this type of back pain is often termed ‘non-specific’ and we should see this as a positive diagnosis as it means nothing serious is wrong. It could still hurt a whole lot though.
  • The term ‘non-specific’ means the tissue, not non-specific to you or has no origin. YOUR PAIN IS ALWAYS REAL AND SPECIFIC.
  • Non-specific pain often responds well to moving and although we cannot give an exact label does not mean we cannot give some ideas to help or a basic explanation about why you might have back pain.

Other Factors

  • Lots of different factors (many which you may have not considered) can affect your back pain.
  • This can mean that you feel your back pain has a life of its own but it may be that you have not been informed about or considered all of the potential contributing factors.
  • These other factors can include abnormal sleep, lots of life stressors including work and family, feeling that the pain will never go and negative beliefs about your back and performing daily activities.
  • Its probably not your spinal posture, your pelvic tilt, a teeny weeny muscle not firing or something needs to be put back into place causing your back pain. How do we know? We have studied this stuff to death.
  • If you have been told this before it could mean your therapist is not up to date with the latest research in this area. You may have been given lots of opinions previously and it can often be confusing for you and hence the need to be aware of the scientific data in this area.

Treatment

  • There are NO magic treatments for back pain that work for everybody, unfortunately.
  • It might not be one singular problem but a few different things happening together. A minor pain might be exacerbated by other things that are making you a bit more sensitive.
  • Your therapist should be able to give you some basic advice or point you in the direction of others who can if it needs more specialist help.
  • Lots of different treatments can help in the short term, such as a few hours or days, but don’t simply put your recovery in someone else’s hands. This has been shown to often be worse in the long term.
  • You may have to avoid aggravating activities in the short term but make sure you go back to doing them. Nothing should be off limits in the long term. Don’t let anyone tell you otherwise.
  • People who feel they need to protect their backs can also have worse outcomes.
  • Learning more about what helps you and what makes you worse is important to help you manage your back pain. Your therapists should help you do this.
  • Movement and exercise might help.
  • Unfortunately, there are no magic exercises for back pain. Find what you enjoy and just do it. This could be Pilates, strength training, a sport with friends or simply going for a walk in the park.
  • Don’t feel you have to really push yourself to get stronger or fitter but it is good once in a while to exert yourself. This gets your body used to doing it.
  • Moving and exercising can help us build confidence in our bodies and this might be key to recovery rather than fixing a physical problem.

Persisting Back Pain

  • The common term for persisting pain is chronic pain, The term chronic does not mean ‘worse’ it is actually just a general term for pain that has gone on for longer than 3 months.
  • How we respond to back pain might play a role in how long it lasts. If you change what you do in terms of activity such as avoiding things or think very negatively about your pain and your recovery
  • We could see persisting back pain as our protective systems, in this case, pain, doing its job too well.
  • Although pain is normal and a good thing, we could see it a lot like red wine. A little bit is great, but sometimes we can have too much of a good thing and it leaves us with a hangover.
  • Persisting pain is currently seen as a problem of the protective system itself rather than simply reflective of the state of your body.
  • The more we work the mechanisms that contribute to pain the stronger they can get. It’s a bit like working your bicep in the gym. Just like your muscles the protective system can adapt and get better at protecting you.
  • Unfortunately, this means that the things that did not use to cause you pain now can do and may explain why you can be very sensitive to things that used to be normal.
  • All of this does not mean you can’t get better but it is not as simple as finding an ‘off’ switch.

Clinicians Advice

  • Sheren Gaulbert – Stay connected with people who matter in your life/engage in activities you value
  • Karen Litzy – Don’t consider yourself broken or damaged goods
  • Ash James – It’s often better to be at work than at home. You will move more, rest less, and get back to normal stuff sooner
  • Kjartan Vibe Fersum – Important to have a shared plan (with your therapist) to move forward with
  • Tom Goom – It’s good to experiment with movement, relax into it and see what helps pain and stiffness. Movement is medicine, and like medicine, it has a dosage, experimentation is needed to find the right dose for you
  • Claire Higgins – Your back is designed to be strong. It can so easily be visualized by patients to be a stack of blocks which could be “crushed” or “topple” at any moment. Education on how our backs are super strong and to trust in them is important.
  • Claire Higgins – Focus on the things which turn your pain down, restoring balance e.g. exercise, meeting friends for coffee, being in the great outdoors.

Degenerative Disc Disease Correlation To Pain Doesn’t Matter As Much As You Think

He came in with a look that resembled someone in grief.

I asked if he was okay and his response was a bit surprising.

“I was just told I have a disease which is causing my back pain, as a result, the pain may never go away.”

As I inquired more he told me the diagnosis was degenerative disc disease, which was causing his spine to shrink and as a result, it was causing the low back pain he was experiencing and would now have to seek treatment on a weekly basis just to deal with it.

This once active person (in his 50’s) was now disheveled because of this MRI diagnosis he had been given by another practitioner, he felt hopeless.

Why MRI Is Just One Tool That Should Be Used

Stories like this happen all too often with our patients.

They experience some sort of low back pain, (which usually they have never experienced before) and their doctor or other healthcare practitioner orders an x-ray or MRI and the results seem catastrophic. They are diagnosed with a “disease” or “syndrome” of some sort but aren’t given any really good information surrounding their condition.

While there is a possibility that disc degeneration (DDD) could be a contributing factor to their pain, it’s not as simple as just looking at some medical imaging to get a proper diagnosis.

There are several contributing factors including environmental factors, genetics, and associations with heavy physical work, lifting, truck-driving, obesity and smoking (smoking has been found as a risk factor for pain and DDD) found to be the major risk factors. However, these do not point to a clear pattern between degeneration and clinical symptoms.

Something that doesn’t get mentioned as often, is how this is also simply a part of normal aging. One systematic review points out some interesting facts to show just how much this happens. When looking at 3110 images of asymptomatic people the review showed: 

  • Prevalence of disc degeneration in people at 20 years old was 37% which increased to 96% in 80-year-olds.
  • Disc bulges occurred in 30% of people at 20 years old and 84% in those at 80 years of age.
  • Disc protrusions were 29% of 20-years-old and 43% of 80-years-old.

And all of these individuals weren’t experiencing any pain!!

Another study showed changes in the disc at multiple levels were more common in the elderly (in this case above 60 years) as well as other degenerative changes around the facet joints, ligamentum flavum, and disc bulges.

Even though degeneration has been seen in the younger population as well, there is little correlation between radiological findings and pain. Quite often people whose imaging shows major issues have no pain and those who present with minor signs experience severe pain.

Unfortunately, many of these people are referred for surgery (usually a spinal fusion) which eliminates motion and can lead to degeneration of adjacent parts of the spine. Another part of the problem here is this only addresses a symptom, not the cause and the surgical outcomes are not great. It is also important to note that 70-80% of people who have surgical indications for back pain or disc herniation recover whether they have surgery or not.

These surgical referrals usually happen because imaging has been used as a diagnosis, rather than just a tool used in the process. This isn’t to say imaging shouldn’t be used, but it should not be the only thing used. Overall we see the association between MRI findings and DDD are unreliable, so the importance remains on our clinical reasoning and of course, patient history as well as looking for any neurological deficits.

The Role Of Depression

Now that we understand DDD risk factors, it’s age-related changes, and correlation with pain there is another factor we need to look at. 

Depression. 

In a three year study looking at veterans who were asymptomatic with low back pain, they were given repeated MRI’s over this three-year span. The researchers made a point of not telling the participants the results of what they saw as they didn’t want the patients to alter their symptoms by becoming sensitized to trivial issues or amplifying their symptoms. 

Imaging findings varied, some discs were less severe, or even normal, and some became worse. The study concluded that central stenosis, nerve root contact, and disc extrusion were the most important imaging findings that may be risk factors for future back pain, however, protrusions were not a risk factor. 

But, the strongest predictor for low back pain was depression. 

Of those who self-identified (and were being medically treated for it) as having depression, their pain scores were greater at EVERY follow-up, whereas the progression of disc changes was only occasionally associated with new pain. Some of the participants also pointed out their activities were limited because of their depression. 

As we know (when reviewing the clinical guidelines of low back pain) bed rest used to be one of the main recommendations for those dealing with acute low back pain, but now exercise and movement is the far better recommendation. When we look at discs exercise does not affect them adversely and they respond well to long term loading strategies. 

So, think about that patient who comes in and is catastrophizing about the diagnosis they have just received. We know part of what we have to do is provide reassurance, in fact, this is a MAJOR part of what we have to do. Looking at all the information we have just discussed, letting them know that disc degeneration is a part of normal aging, there is little correlation between their diagnosis and pain (unless there are neurological symptoms) and quite often the issue resolves itself without surgery. Could we actually reverse their catastrophizing? Could we also assist this by encouraging them to exercise, even by getting them moving on your table to show that movement is safe? We know that exercise has great results in helping with depression and now we know it also helps with disc health, so aren’t these the things we should pay more attention to rather than focusing on MRI results? I’d say yes…and the research agrees. 

Articles Of The Week April 14, 2019

 

People will do all sorts of popular treatments for different parts of their body. There is a new trend where women are getting laser therapy on their vagina for a variety of reasons, but is the treatment actually valid? Well…there is still research to be done.

“Do Vaginas Need Rejuvenating?” – Sandy Hilton

Patient education and communication is a crucial part of treatment, but how much of what we say do they remember? This is where effective communication may be using short simple messages to help with education retention.

“Pain Science Education” – Lynita White

When it comes to our mental health, it turns out exercise does more for it than money. Although I’m sure most of us would have guessed that, there’s actually research out of Yale and Oxford that prove it.

“Exercise Makes You Happier Than Money” – Ruqayyah Moynihan

Continuing with mental health, how about its relationship with food? If we were to include education on nutrition as part of mainstream healthcare is there a potential for real change? This article argues it would.

“Why Isn’t Nutritional Therapy A Primary Therapy For Mental Illness?” – Eirik Garnas

Research is showing us that one of the best things we can do for arthritis, is loading the affected joints. When loaded properly we can actually combat the effects arthritis has on the joints.

“Arthritis And Movement: Your Weightlifting Prescription” – Mike DeMille, DPT, and Erin Murray

How Recognition And Communication Can Help Cauda Equina Syndrome

Sometimes a patient walks into your clinic and it’s hard to decipher what’s going on with them.

It may be something we’ve never seen before, their signs and symptoms don’t add up, or their pain doesn’t seem to correlate to their description of the cause. When things don’t seem to add up, our clinical reasoning has to jump into full effect to figure out what’s going on.

Looking at the red flags of low back pain, one of the conditions that really stands out is Cauda Equina Syndrome.

While it is rarely seen in practice (I have yet to ever encounter a patient with it) it is something we should have a working knowledge of, so our clinical reasoning can jump into action.

Early recognition and referral to medical help can make a massive difference in its development and effect on a patient, so we have a responsibility to recognize and refer out when necessary, and in this case, it is!

Recognizing Cauda Equina

The Cauda Equina is a bundle of nerve roots that angle down in the vertebral canal from the end of the spinal cord, which looks like wisps of hair, giving it its name, meaning “horse’s tail”.

What causes Cauda Equina Syndrome is usually some sort of compression happening at the nerve roots around the lumbar to sacral area. The most common causes are:

  • Lumbar disc herniation, prolapse, or sequestration (one systematic review showed 45% were disc related)
  • Smaller prolapses due to spinal stenosis.

The less common causes are:

  • Epidural Haematoma.
  • Infection.
  • Primary and metastatic neoplasms.
  • Trauma.
  • Post-surgical.
  • Prolapse due to manipulation.
  • Chemonucleolysis.
  • After spinal anesthesia.
  • Patients with Ankylosing Spondylitis.
  • Gunshot wounds.
  • Constipation.

All of these things are important to ask during a patient history if you suspect a possibility of Cauda Equina, but more important is their clinical presentation. It may present as: 

  • Low back pain.
  • Saddle anesthesia.
  • Bilateral sciatica.
  • Weakness of their lower extremities.
  • Paraplegia.
  • Bowel, bladder, or sexual dysfunction.

The most commonly seen are low back pain and radicular leg pain because of tissue irritation around the lumbar spine.

When it comes to assessing patients who could possibly be dealing with this, one review showed they can be placed into three groups: 

  1. CESS (Cauda Equina Syndrome Suspicious or Suspected)
    • Bilateral radiculopathy.
    • Subjective sphincteric problems with no objective evidence of CES.
  2. CESI
    • Subjective symptoms and objective signs, but voluntary control of urination.
  3. CESR (Cauda Equina Syndrome Retention)
    • Neurogenic retention of urine with a paralyzed, insensate bladder along with urinary incontinence.

Now just as we see some “red flags” with low back pain, CES has also been divided into red flags and white flags and are divided into:

  • Definite Red Flags
    • Bilateral Radiculopathy.
    • Progressive neurological deficit in the legs.
  • Possible Red or White Flags
    • Impaired perineal sensation.
    • Impaired anal tone (not that I’m suggesting you should ever try to palpate this).
    • Urinary difficulties that are unspecified.
  • Definite White Flags
    • Urinary retention or incontinence.
    • Fecal incontinence.
    • Perineal anesthesia.

With this outline, we define the “true red flags” as someone who has bilateral radiculopathy, difficulties with urinating, or changes in bladder function, along with the loss of perineal sensation. However, there is nothing that gives a clear diagnosis because so many of the symptoms are objective. It is recommended that MRI is important, not because it can diagnose, but rather it shows which people with red flag symptoms have significant compression of the nerve roots, which may result in treatment before the development of the white flags which are more severe.

White flags are a way of saying “defeat or surrender” as the signs are often seen too late and are irreversible. Therefore the review outlining these red and white flags makes the argument that white flags should be removed because treatment at this stage might be too late to recover and avoid long term harm.

Another review even pointed out these different subclasses were too ambiguous as far as signs any symptoms go, so they should be avoided as well.

Then the argument is made that CES diagnosis should revolve around one or more of the following being present:  bladder or bowel dysfunction, reduced sensation in the saddle area, and sexual dysfunction with possible lower limb neurologic deficits.

Clear Communication And Reassurance

As we have talked about before, when it comes to low back pain, patient reassurance is a crucial aspect of helping them deal with these issues.

Much of the evidence shows good outcomes occur when patients have decompressive surgery early before there are incomplete lesions on the nerve. However, it is unclear as to which exact surgery (there are a few different types) works the best and is another factor that could affect patient outcomes.

So the important thing is for us to recognize these symptoms, realize there is an issue, and have our patients get the appropriate help, (which is most likely a trip to the hospital), as early recognition and treatment is key.

We want to ensure when talking to our patients that we are using clear and easily understandable terms, as well as proper descriptive terms when referring to doctors as this is a rare condition and is estimated a doctor may only see this once in their career.

It is crucial that our communication with patients is centered on them, not only in the way we talk, but also in the way we listen, as it has been shown they use very explicit language in their description of symptoms. It is then important for us to use terms they understand. Much of the research uses terms like “micturition” and “incontinence” which came across as very vague and hard to understand for patients. Rather, using terms like “urinating”, or “difficulties using the restroom” would be more appropriate. One patient was told their issue was serious if they were incontinent, yet the patient would be able to “force” themselves to use the toilet, so didn’t understand this was an issue.

So, clear communication is key to the emphasis and seriousness of their condition, as well as the importance of getting to the hospital quickly (better outcomes within 48 hours of recognition and treatment). While these can be difficult conversations to have, they are crucial ones because if this isn’t recognized and dealt with, there can be long term and VERY undesirable consequences, which are quite simply life altering. We can play a major role in this for our patients. While it may be difficult to have conversations (and some would argue we shouldn’t) centered around sexual dysfunction and using the toilet, we owe it to our patients as healthcare professionals to not only be open to,  but willing to talk about this for their better outcome.

A Novel Mobilization for Acute Ankle Inversion Sprains

 

The case in the video was a severe ankle inversion sprain on the left and moderate on the right. The patient is a high-level gymnast who injured herself tumbling during a floor routine.

The video below was taken almost a week after the sprain. She had significantly decreased mobility with pain in all planes. Normally I would try a posterior glide to the lateral malleolus and ankle inversion/plantarflexion, which has worked on her in the past with great results. This time, that was too painful as was lateral malleolus contact.

Instead, I tried slacking the irritated skin and ligaments while gradually moving the forefoot/ankle into dorsiflexion and eversion. This was pain-free and after working my way to end range, her active/passive non-weight bearing range was much better and her gait was nearly pain-free. This got her started with loading and was easily replicated for an hourly home exercise program to modulate pain.

A Novel Mobilization for Acute Ankle Inversion Sprains

The case in the video was a severe ankle inversion sprain on the left and moderate on the right. The patient is a high level gymnast who injured herself tumbling during a floor routine. The video below was taken almost a week after the sprain. She had significantly decreased mobility with pain in all planes. Normally I would try a posterior glide to the lateral malleolus and ankle inversion/plantarflexion, which has worked on her in the past with great results. This time, that was too painful as was lateral malleolus contact. Instead, I tried slacking the irritated skin and ligaments while gradually moving the forefoot/ankle into dorsiflexion and eversion. This was pain free and after working my way to end range, her active/passive NWB range was much better and her gait was nearly pain free. This got her started with loading and was easily replicated for an hourly home exercise program to modulate pain.

Posted by Modern Manual Therapy on Monday, January 22, 2018

Models Of Pain And Movement

 

There are various models used to understand pain: the neuromatrix model, the biopsychosocial model; Louis Gifford’s Mature Organism Model; the Onion skin model, the biomedical model. And for motor learning and physical training, there is the constraints based model, or dynamic system theory, the various Russian sports science models, non-linear pedagogy, etc.

 

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I often see debate as to the relative merit of these models, which is a good thing. But what I think is not such a good thing is when people argue that because a model has a certain flaw or limitation, it is fatally deficient. Or that using this model will always lead to error. Or that existing problems with current models require a complete and radical revolution in our thinking. These arguments are particularly common in regard to models about the brain because let’s face it, the brain is pretty hard to model.

The way I look at it, all models are necessarily wrong, at least to some extent. But some models are still useful. We need to be aware of how a particular model might lead us astray, but we also need to appreciate how it can provide insight.

Building models is a fundamental part of trying to understand the world in any systematic or organized way. The world has too many details and complexities to be taken in all at once. In order to really understand a particular phenomenon, we need to focus on certain essential details while ignoring others.

For example, to understand the movement of large objects in response to forces, we focus on the mass and velocity of the object and the magnitude and direction of the forces applied to it. But we ignore non-essential but very real details like the color of the object, the shape of the object, or even the effects of friction. The result is a model with simple equations like force equals mass times acceleration.

We can test the accuracy of the model by seeing whether it makes accurate predictions. If it does or leads to better understanding and control over the events we are trying to explain, it is a success. Further progress can be made by noting the limitations of the model, arguing about whether other models are better, making improvements to existing models and so forth.

Although we can improve the accuracy and utility of models, they can never be complete or accurate representations of the world. In order to fully model the world, we would have to build another world! That’s impossible, and it wouldn’t really help anyway. So models are not mirrors of reality, but simplified reflections. They are, therefore, to at least some extent, “wrong.” But again, they can be incredibly useful.

Newtonian mechanics allows us to make amazingly accurate predictions about the movement of large objects like planets. But it fails to describe events accurately when objects are very small or moving near the speed of light. Under these circumstances, we need different models – the theory of general relativity or quantum mechanics. So Newton’s “laws” are not universal, but they remain accurate in the “middle-sized” world that is our usual area of concern.

Here’s a relevant quote from Sean Carroll (a very smart physicist) in his new book The Big Picture:

Our best approach to describing the universe is not a single, unified story but an interconnected series of models appropriate at different levels. Each model has a domain in which it is applicable, and the ideas that appear as essential parts of each story have every right to be thought of as “real.” Our task is to assemble an interlocking set of descriptions, based on some fundamental ideas, that fit together to form a stable planet of belief.. . .

Our fundamental ontology, the best way we have of talking about the world at the deepest level, is extremely sparse. But many concepts that are part of non-fundamental ways we have of talking about the world — useful ideas describing higher-level, macroscopic reality — deserve to be called “real.”

 

The key word there is “useful.” There are certainly non-useful ways of talking about the world. In scientific contexts, we refer to such non-useful ways as “wrong” or “false.” . . . Every scientific theory is a way of talking about the world. The world is what exists and what happens, but we gain enormous insight by talking about it — telling its story — in different ways.

I agree!

The human body is one of the most complex organizations of matter in the known universe. To understand it, we must build models, use metaphors, and deal in abstractions. This necessarily involves ignoring certain details, creating simplified pictures, and relying on metaphors that have the potential to mislead. But we have no choice! Models and metaphors are indispensable thinking tools for understanding the body. Is the brain a computer? The heart a pump? The kidney a filter? The nerves telephone wires? In some ways, yes, and others no.

Each model is a different perspective from which to see the world, with its own unique insights and blind spots. For example, you can look at movement or pain from the perspective of the musculoskeletal system, the nervous system, the metabolic system, the immune system, or the endocrine system. You can take a microscopic view to consider the behavior of individual cells, or zoom out for a big picture of the relationship between larger systems. Some perspectives might be highly informative for a wide variety of purposes, and generally, foster an accurate perception of the viewed object. These perspectives are great. Others may get you looking in completely the wrong direction. These perspectives suck. But there is no one perspective that can offer a complete understanding of a multi-dimensional phenomenon like pain, movement, or any other event in the human body.