Back Pain Myth Busting Part 1

This series of blogs is to help bring some clarity with what to expect with back pain and what the evidence is telling us.

This week I wanted to pull out some facts regarding back pain and the public perception of the most prevalent musculoskeletal injury. The idea is to give you more confidence in using your back during injury but also trying to clear the stigma associated with this condition.

 

1 Back Pain is normal factor in life

Up to 84% of people will have some form of back pain in their lifetime (1). It has become inevitable that this will happen at some point unless you’re a hermit. The good news is that only a small percentage that don’t fully recover.

Most acute back injuries are the result of a simple strain or sprain and expected recovery is excellent. Within the first two weeks of an acute episode of pain, most people will report a significant improvement in their symptoms with up to 90% full recovery within 6 weeks. Only 2-7% of people develop chronic, disabling problems (2).

2 Scans are rarely needed – be careful what you wish for

This one is great, if you put the people of Newmarket through an MRI scan about 60% will have some abnormality even if they don’t have pain. (3, this wasn’t a study of the Newmarket population) (4)

Wait, so if an MRI scan can show a disc prolapse without pain, could that mean the pain may not be associated to the disc identified? Some of us need a “label”, once being diagnosed with a disc prolapse it becomes easy fall back into the “what can I do? I’ve got a disc prolapse”. This can cause a heightened fear of moving normally and exercising, which happens to be the opposite approach to rehabbing this condition. (5)

Consider this, only 5% of lower back strains are the direct result of a disc herniation (6). It’s not to say they can’t be the cause of pain but there are many other structures and factors involved with lower back pain.

  1. Balagué et al, (2012) Non-specific low back pain. Lancet.
  2. Kinkade, (2007) Evaluation and treatment of acute low back pain. Am Ac of Family Phys
  3. Jensen et al, (1994) Resonance Imaging of the Lumbar Spine in People without Back Pain, N Engl J Med
  4. Teraguchi et al, (2013) Prevalence and distribution of intervertebral disc degeneration over the entire spine in a population-based cohort: the Wakayama Spine Study.
  5. Shnayderman et al, (2013) An aerobic walking programme versus muscle strengthening programme for chronic low back pain: a randomized controlled trial. Clin Rehabil.
  6. Lateef et al, (2009): What is the role of imaging in acute low back pain? Curr Rev Musculoskelet Med

Hold the Ice – in RICE

Questioning the reasoning of using ice when injured. A lot of current evidence shows that ice may hinder the recovery of an injury.

Changing brings difference, difference brings progress and if progress was easy to achieve it would not be so hard to accomplish. 

This is always going to be a difficult topic to discuss when dealing with an acute injury. The knee jerk reaction is to apply the ice to the sprained ankle or twisted knee as it’s something commonly used in general practice for over 40 years. This is not me condoning the use of the ice if you’ve had good experiences with it in the past, just providing another way of approaching the recovery of an injury with current literature and using clinic reasoning.

Most of us have been familiar with R.I.C.E. (Rest, Ice, Compression, Elevation) for the initial treatment of acute injuries, which was first published in sports medicine book by Dr Gabe Mirkin in 1978. The acronym was easily remembered and became engrained in all environments with little to no challenge of its overall effectiveness. In the last 7-8 years, there has been more evidence published to question inclusion of ice as an essential tool for an acute injury. In fact, Dr Mirkin has reviewed the current research and done a complete turn on his own recommendation of using ice.

Why use Ice?

The whole idea of icing was to restrict blood flow to the damaged structure, to minimise swelling and bleeding. This was to be applied at regular intervals for the first 2-3 days. It was believed that the swelling restricts range of motion and delays the overall length of recovery. Also, it works as a natural numbing agent to help with pain relief

What’s happening when we get injured?

A multitude of things begin to happen in the body when faced with an injury. You may be aware of the three stages of an injury; acute inflammation, proliferation and remodelling. In that inflammatory stage the blood vessels dilate and increase permeability allowing an increased supply of white blood cells (Microphages and leukocytes) to the damaged site. These blood cells will help break down the damaged tissue and to promote healing will produce growth hormones. There is also increased swelling and the joint becomes more restricted and increases sensitivity to pain which both protects the joint from further damage. Our other less known system in the body, the lymphatic system (the “sewerage” system) slowly helps drain the area of fluid and other by-products.

What is the current evidence showing?

If blood flow is restricted through ice, this limits the release of white blood cells to the area. Lu (1) found that with a steady supply of growth hormone soft tissue can heal at a normal rate compared to tissue with limited/no supply of the hormone. Also, when ice is applied it has a longer lasting effect on vasoconstriction even after the ice has been removed (2), meaning the supply of these white blood cells is depleted for a prolonged time.

Also, the lymphatic system that I mentioned which helps draw away swelling and the “junk”, this is assisted by the pumping action of muscle contractions. Bleakley (3) demonstrated that the strength of a contraction is depleted when iced is applied and this would impact on the pumping action to lymph nodes that help draw swelling away from the injured site. Also, icing the injured site causes changes to the permeability of the lymphatic system causing fluid to leak back into the injured site cause more swelling (4 – I know it’s old but it was a foundational study).

Another study in 2011 (5) broke down the stages of healing even further, the soft tissue was sampled physiologically and under a microscope, comparing damaged tissue that had been iced and non-iced.

Time after injury No Icing Group Icing Group
12 hours Macrophages were found within the necrotic muscle fibers (Macrophage migration to an injured site to phagocytose the necrotic muscle fibers is essential for “clean-up”) Less macrophages were found within the necrotic muscle fibers
Day 3 Regenerating muscle cells present Reduced regenerating muscle cells
Day 4 Normal sized muscle cells produced Smaller sized regenerating muscle cells
Day 14 Normal maturation of the regenerating muscle fibers Maturation of the regenerating was visibly reduced
Day 28 Cross-sectional area of the regenerating muscle was 65% greater than the icing group Collagen fibers were seen only among the bundles of muscle fibers as it is seen in healthy muscles Regenerating muscle fibers was significantly less in the icing group (P < 0.01) Abnormal collagen formation where collagen fibers surrounded each muscle fiber

If no ice then what are we left with?

So now we know ice doesn’t need be put on this pedestal of being an essential tool in recovery post injury. It still has its place for pain modulation, but only for short periods otherwise it will cause prolonged vasoconstriction. Also along the lines of avoiding limiting the inflammatory process, we need to refrain from anti-inflammatories and stick to a mild pain killer (ie Panadol) if struggling with discomfort. If this does not control your pain levels, seek your GP for advice on stronger medication

Following an injury, we fear the worst which is understandable, therefore it’s important to have it assessed by a health care professional to determine the degree of the injury and be receive the best advice, treatment and referrals if needed (i.e. X-ray). To kick start the repair process, begin moving the joint or damaged tissue within a comfortable range as soon as possible at regular intervals through the day. When resting consider having the area elevated above the heart and wear some compression. This will all assist with the lymphatic drainage, putting your body in the best environment and allowing it do the work.

Other options worth considering if you have a high pain tolerance and a keen mobiliser. I’ve seen some good results with regular intervals of using voodoo floss recovering from injury. Although there is no literature to support voodoo bands. But in terms of releasing myofascial tissue which is the main structure the band is impacting on, this can improve lymphatic drainage (6).

There is no harm in using ice, as we’ve been using it for a few decades now, but looking at the latest research and its impact on recovery times, you might want to consider your options before chucking on the bag of peas.

  1. H. Lu et al, (2010) Macrophages recruited via CCR2 produce insulin-like growth factor-1 to repair acute skeletal muscle injury. The FASEB Journal
  2. Khoshnevis et al, (2015) Cold-induced vasoconstriction may persist long after cooling ends: an evaluation of multiple cryotherapy units. Knee surgery, sports traumatology, arthroscopy : official journal of the ESSKA
  3. Bleakley et al, (2012) Should Athletes Return to Sport After Applying Ice? Sports Med
  4. Meeusen, R. (1986) The use of Cryotherapy in Sports Injuries. Sports Medicine.
  5. Takagi, R, et al, (2011) Influence of Icing on Muscle Regeneration After Crush Injury to Skeletal Muscles in Rats. J of App Phys
  6. Bruno C, (2016) Lympho-Fascia Release and Viscerolymphatic Approach To Fascia,