Back Pain Myth Busting Part 5

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

And the final part of this Lower back pain blog is regarding factors in our life that we wouldn’t think influence our pain. Also, there is hope for people dealing with persistent back pain.

 

9 Sleep deprivation, stress, low mood and worry influence back pain

Some people feel that pain can only be mechanical, but there are a few other factors that affect our pain perception when we have lower back pain. Life events that cause increased levels of stress or depression can enhance the pain we feel. Understanding these factors and trying to take control of them will help. Studies have shown that with a cognitive approach dealing with stress’, fears relating to the injury and of movement will help lower pain scores and result in good outcomes (1)

 

10 Persistent back pain can get better

As previously noted in the last point and the other parts of this blog, there are many factors influencing back pain and not every individual is the same, requiring a tailored treatment plan to match their needs. Most people with persistent back pain will likely need to address non-physical factors as mentioned in the last point (2).

It is very common as most treatments only address one factor, if someone goes for a massage for their sore muscles, but fails to address their stress at work or fitness levels. You can understand why problems likes this become an “on + off” issue throughout life.

Identifying the different contributing factors for each individual and trying to address them, pain can be greatly reduced and people can live a happier and healthier life.

 

1.     O’Keeffe et al, (2015) Individualised cognitive functional therapy compared with a combined exercise and pain education class for patients with non-specific chronic low back pain: study protocol for a multicentre randomised controlled trial, BMJ Open

2.     O’Sullivan, P. (2012) ‘It’s time for change with the management of non-specific chronic low back pain‘, British Journal of Sports Medicine, 46(4), 224-227.

Back Pain Myth Busting Part 4

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

Next up are two biggies. How should I sit and can I lift with a spinal injury? Posture is an important factor with both positions but it’s understanding how it can be effective while recovering.

 

7 The perfect sitting posture may not exist

The body is designed to move. If we sustain a position for too long, we end up loading an area more than it’s designed for. This can either be in a slouched position or even sitting erect. It’s important to alternate our sitting positions to avoid pain and adaptations (1). This can be done with changing sitting positions, getting up regularly and doing tasks in standing that you would normally do sitting (i.e. taking phone calls). Try to change position every 20minutes.

Knowing that movement through range in sitting is necessary to gain confidence in your spine instead of being rigid/protective. (2)

 

8 Exercise and resistance training

Lower back pain can cause people to fear and avoid certain activities that involve bending, lifting and twisting (3). However, it is important that we encourage this within a safe environment, to gain confidence and reach better outcomes.

Initially it may be sore practising these movements, but as mentioned previously it’s about understanding the type of pain you feel. This will help strengthen the spine and supporting structures, getting you back to lifting, running and jumping.

Studies have shown great benefits and long-term safety of various types of exercises (4) including high load resistance training (5).

 

1.     Zemp et al, (2013) In vivo spinal posture during upright and reclined sitting in an office chair. BioMed Research International.

2.     Baumgartner et al, (2012) The spinal curvature of three different sitting positions analysed in an open MRI scanner. The Scientific World Journal.

3.     Thomas et al, (2008) The relationship between pain-related fear and lumbar flexion during natural recovery from low back pain. Eur Spine J.

4.     Steele et al (2015) A Review of the Clinical Value of Isolated Lumbar Extension Resistance Training for Chronic Low Back Pain; American Academy of Physical Medicine and Rehabilitation

5.     Pieber et al (2014) Long-term effects of an outpatient rehabilitation program in patients with chronic recurrent low back pain; Eur Spine J

Back Pain Myth Busting Part 3

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

You may have heard of the phrase, Pain doesn’t hurt. In some cases, it doesn’t. Also, the urgency for having spinal surgery may want to be reconsidered based on the research.

 

5 More pain does not mean more damage

As mentioned previously the spine is a complexed structure with many different factors effecting it from a physical, mental and environmental perspective. You could have two individuals with the same injury, but can feel different sensitivities of pain (1).

Our nervous system has an influence on the pain we feel and can sometimes get stuck in a loop if the injury is poorly managed. So, even once it has healed we can still experience discomfort.

Our coping strategies vary depending on different types of pain. Once we understand that some pains are not causing damage, our quality of life can be drastically improved. (2,3)

 

6 Surgery is rarely needed

There are only a small proportion of people with back pain that need surgery. Following clear guidance from your physio or Dr by staying active with exercise, manual therapy when needed, positive reinforcement of movement, understanding your injury and good pain management we see excellent results.

The statistics for successful outcomes following surgery vary from one country to another and between surgeons. But there is evidence showing that the outcomes after having surgery are similar to non-surgical treatments over a span of 1-2 years (4,5).

 

1.   Vernon H, (2010) Historical review and update on subluxation theories. J Chiropr Humanit.

2.   Taylor et al (2014) Incidence and risk factors for first-time incident low back pain: a systematic review and meta-analysis: The Spine Journal October

3.   George et al, (2012) Predictors of Occurrence and Severity of First Time Low Back Pain Episodes: Findings from a Military Inception Cohort. PLoS ONE 7(2): e30597

4.   Brox et al, (2010) Four-year follow-up of surgical versus non-surgical therapy for chronic low back pain Annals of the Rheumatic Diseases

5.   Wynne-Jones et al, (2014) Absence from work and return to work in people with back pain: a systematic review and meta-analysis. Occupational and environmental medicine

Back Pain Myth Busting Part 2

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

Moving on from part 1 are some misunderstandings of an old medical phrase and some advice that should only be left to the most severe of cases.

 

3 Back pain is not caused by something being “out of place”

There is literally no evidence of joint subluxations of the spine when under X-ray, MRI or any other type of imaging (1). Yet the phrase of the spine being “out of place” is still used and that it needs to be realigned like pieces of Lego.

As humans, we are not symmetrical and there are slight discrepancies, more so with scoliosis, Scheunemann’s etc. But we adapt to these changes throughout life.

It is worth noting a popular treatment for being “out of place” are joint manipulations. This is not relocating the joint, but causing cavitation (the formation of gas bubbles within the joint causing an audible sound). This is however effective in providing short term improvements to pain, muscle tone/tension and lowering fear.

 

4 Bed rest is not helpful

If we were to take a trip back to the 80’s you’d likely get told by the Dr to have a few weeks of bed rest and if you’re lucky be prescribed a corset.

We now know with strong evidence that gentle movement and trying to maintain normal activities as comfortably as possible will improve the rate of recovery (2,3).

 

  1. Vernon H, (2010) Historical review and update on subluxation theories. J Chiropr Humanit.
  2. Wynne-Jones, G. et al., 2014. Absence from work and return to work in people with back pain: a systematic review and meta-analysis. Occupational and environmental medicine
  3. Malmivaara et al, (1995) Treatment of acute low back pain: bed rest, exercises, or ordinary activity? N Engl J 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,