Study: When is bending too much?

This recent study looked at sustained bending and the time it takes before our postural muscles give in and we begin to rely on our passive structures for support.

Alessa 2017

How long is too long, to be in a forward, bent posture? Many of us spend hours doing house chores; weeding, DIY, working on the car etc. Not to mention the time spent leaning over a computer desk or looking down at your phone.

Back pain

Your muscles play an amazing role of suspending us in these positions, but just like with exercise our muscles will reach a point of fatigue. When the postural muscles aren’t able to provide the support we then rely on “passive” structures like ligaments and fascia, which is not their primary role, eventually leading stress and increased risk of injury.

This study looked at 2 angles of the spine leaning forwards and found that within 40 seconds the participants transitioned from the support of postural muscles to the passive structures. While this was found to be a natural transition the prolonged strain on the passive structures has been shown to increase the risk of lower back pain as suggested in another study.

As mentioned in a previous blog, these positions are not “wrong” but it’s better for the overall health of the spine to regularly change position and break from sustained load on an individual structure to provide balance.

Abstract

Static trunk bending is an occupational risk factor for lower back pain (LBP). When assessing relative short duration trunk bending tasks, existing studies mostly assumed unchanged spine biomechanical responses during task performance. The purpose of the current study was to assess the biomechanical changes of lumbar spine during the performance of relatively short duration, sustained trunk bending tasks. Fifteen participants performed 40-s static trunk bending tasks in two different trunk angles (30° or 60°) with two different hand load levels (0 or 6.8 kg). Results of the current study revealed significantly increased lumbar flexion and lumbar passive moment during the 40 s of trunk bending. Significantly reduced lumbar and abdominal muscle activities were also observed in most conditions. These findings suggest that, during the performance of short duration, static trunk bending tasks, a shift of loading from lumbar active tissues to passive tissues occurs naturally. This mechanism is beneficial in reducing the accumulation of lumbar muscle fatigue; however, lumbar passive tissue creep could be introduced due to prolonged or repetitive exposure.

 

Alessaa F. et al (2017) Changes of lumbar posture and tissue loading during static trunk bending. Human Movement Science

Continue reading “Study: When is bending too much?”

What’s causing my muscle tightness?

Muscular tightness is one of the disruptions to normal movement and if not managed well can lead to possible injury. Identifying your tightness and using specific strategies will help relieve tension.

One of the main issues patients struggle with is muscular tightness. They get a feeling of pain or tightness and an inability to relax the muscle.

What is tightness?

When looking at patients I need to find out if they have mechanical stiffness or the “feeling” of tightness or a combination of both, as this would direct my treatment plan.

Is the range of movement limited? does it have a soft or hard end feel? Are movements a struggle at end range, feeling heavy? What’s the rest feeling like, is it a constant tightness?

While we can have mechanical tightness of a joint or muscle, there are also the “feelings” of tightness. You might get your hands to the floor with your legs straight and feel the hamstrings tightening. While another person could do the same, get to their knees and not have tightness.

What causes the feeling of tightness?

Tightness is a sensation like many others, including pain. What we understand from pain is that this is not always brought on physically, but also by the perception of threat.

pathway-of-a-pain-message-via-sensory-nerve-in-injured-muscle,2324600

So like pain, tightness is a protective mechanism from the central nervous system to avoid danger. On a number of levels it detects stressor’s that expose the whole body or specific region to threat.

Examples of this…..

  • Prolonged sitting, without movement we often notice tightness in certain areas, possibly through reduced oxygen supply and increased metabolic toxicity.
  • Stressful situations cause rising cortisol levels and increased activity of the Vagus nerve leading to muscular tightness.
  • Repetitive movement over a period of time causes increased tension.
  • Posture muscle tightnessInjury or pre-existing weakness can cause a guarding response from the nervous system.

Using tightness as a warning sign for these potential threats might allows us to acknowledge the situation and quickly act upon it.

What will help my tightness?

Like all movement patterns, we improve with practice. The same goes for muscle tightness. If we regularly bombard it with neural messages to remain tight we develop trigger points and chronic tightness through a process called central sensitisation. Which makes the tissues more sensitive to pain and tightness.

If we can regularly supply our nervous system with input that is non-threatening we can slowly help desensitise the muscle. But this takes time and regular repetition.

Stretching

Most people with tightness, especially after prolonged rest feel the need to stretch out. But depending on our intended goal there are different types of stretches.

  • Static stretches
  • Active stretches
  • Dynamic stretches
  • PNF (Contract-relax)

While these stretches will help, it might only be temporary without regular repetition and reinforcing the nervous system with good movement.

Strengthening

There is a misconception that resistance training causes our muscles to feel tighter. Mainly due to the effect of DOMS. That feeling of soreness you have the day after a hard workout. But some recent studies have shown that strengthening can be equally, if not more beneficial than stretching.

Improvements in flexibility coming from improved ability to handle higher levels of metabolic stress and lower levels of inflammation. By lowering the threat to the nervous system through increased strength, it allows you to work the muscle through a wider range, without getting a stretch reflex.

Massage and other soft tissue work

Another way to help desensitise these tight muscles is to apply pressure. This could be with the use of a foam roller/lacrosse ball or other manual therapy techniques like deep tissue massage, myofascial release, trigger point release, dry needling.

Relaxation techniques and breathing mechanics

Like in the previous blog, an overactive or dominant sympathetic nervous system can cause muscle tightness. Finding ways of breaking poor postures or shallow breathing using a range of methods like kapalbhati, wim-hof, meditation, yoga etc. Using these methods are just part of the process to lowering overall tightness.

Usually, just following one of these methods individually is not going to be as effective as combining them together. Try to deal with the tightness from all angles.

If guidance is required or manual therapy techniques feel free to call 09 5290990.

Disc Prolapses that Reabsorb

A recent study shown that re-absorption of disc prolapses is higher than previously thought.

Zhong 2017

The Concern and fear that the words “slipped disc” “disc bulge” or “degenerative disc disease” can be worse than the actual symptoms of pain. The image of being broken and not being able to recover. But as previously noted in another blog about MRI scans, a large number of the general public suffer with a disc prolapse without symptoms. They manage to carry out a normal fulfilled life.

This new study of pooled data from the UK and Japan showed a significantly high number of lumbar disc re-absorption. To be precise it was 66.6% (82.94% in the UK I might add!!). All patients received conservative treatment, there was no invasive treatments like surgery or steroid injections.

This goes to show that with patience in your recovery and the right guidance, spinal problems will resolve without being too hasty for surgery.

 

Original Abstract

BACKGROUND: Lumbar disc herniation (LDH), a common disease, is often treated conservatively, frequently resulting in spontaneous resorption of the herniated disc. The incidence of this phenomenon, however, remains unknown.

OBJECTIVE: To analyze the incidence of spontaneous resorption after conservative treatment of LDH using computed tomography and magnetic resonance imaging.

STUDY DESIGN: Meta-analysis and systematic review of cohort studies.

SETTING: The work was performed at The Suzhou Hospital of Traditional Chinese Medicine, Shanghai University of Traditional Chinese Medicine.

METHODS: We initiated a search for the period from January 1990 to December 2015 using PubMed, Embase, and the Cochrane Library. Two independent reviewers examined the relevant reports. The references from these reports were also searched for additional trials using the criteria established in the PRISMA statement.

RESULTS: Our results represent the pooled results from 11 cohort studies. The overall incidence of spontaneous resorption after LDH was 66.66% (95% CI 51% – 69%). The incidence in the United Kingdom was 82.94% (95% CI 63.77% – 102.11%). The incidence in Japan was 62.58% (95% CI 55.71% – 69.46%).

LIMITATIONS: Our study was limited because there were few sources from which to extract data, either in abstracts or published studies. There were no randomized, controlled trials that met our criteria.

CONCLUSIONS: The phenomenon of LDH reabsorption is well recognized. Because its overall incidence is now 66.66% according to our results, conservative treatment may become the first choice of treatment for LDH. More large-scale, double-blinded, randomized, controlled trials are necessary to study the phenomenon of spontaneous resorption of LDH.

Chiro.jpg

Reference

Zhong et al, (2017) Incidence of Spontaneous Resorption of Lumbar Disc Herniation: A Meta-Analysis. Pain Physician

Sitting Posture – How important is it really?

Sitting posture is something that get’s heavily criticised and over analysed. There could be more to it than simple ergonomics.

Your best posture is your next posture

In the last several years sitting posture has been classed as the “new smoking” or a dangerous position that will ruin your life. There are various arguments for and against sitting from different health experts and research. My opinion on this topic comes from my own clinical experience and taking value from all of the other respective parties.

First of all, sitting is not dangerous. But the longer we sit over a prolonged time is not healthy

Our body is dynamic and multi-functional, one of these functions is sitting. What’s up for debate is length of time and position. Recent studies have documented the following long term health risks from prolonged sitting.

diabetes-infographic

**These studies are predictors for potential health risks, but are also contributed by poor nutrition, sleep deprivation and lack of exercise.

What’s the physical problem with sitting?

In unsupported sitting (i.e. on the floor, perched sitting) we have some activity from core muscles that stabilise the spine. With no activity we would collapse into a heap.

Our central nervous system cleverly adapts to positions we hold most in the day. In supported sitting our body adjusts, slowly loosing flexibility in the thoracic spine, hips and hamstrings. The trunk muscles, “the core” reduce activity in sitting and loose their primary function of support when doing physical activities. Other muscles like the glutes, scapular stabilisers and posterior rotator cuff become short or weakened.

With the lack of support our body naturally falls into the path of least resistance and this is when changes in posture begin to happen. Essentially causing us to hang off the tension of ligaments and other soft tissue, instead of support from the tone and strength of stabilising muscles.

Chemical changes are brewing while sitting

The longer we sit without movement puts more stress and pressure specific tissues. Causing reduced blood flow to that area, meaning it gets less oxygen and less removal of metabolic bi-products. The muscle becomes increasingly toxic and acidic.

Luckily our tissues hold acidic sensing Ion channels that detect changes to PH levels. When in an acidic environment it sends our brain a signal and we get the feeling of discomfort.

Choosing to ignore the discomfort and stay in the same position causes an increase in toxicity and will result in the development of the trigger point phenomenon. Another phenomenon called central sensitisation may also happen. When pain signals constantly bombard the brain with pain signals it lowers your pain thresh-hold, making you more susceptible to pain in stressful environments.

Whats the answer to sitting?

Looking at the physical and chemical changes that happen in a sustained position you can see that any position for a prolonged time is not beneficial to us.

A posture that doesn’t move isn’t a postural problem, it’s a problem of movement.

“Neutral” spinal and postural alignment is all well and said. But even sitting in an ergonomically aligned position will feel uncomfortable if sat this way for 8 hours.

To counteract the negative effects of sustained sitting positions, here are some recommendations:

1. Position variation

Look at the postures below. Some of them were traditionally classed as “bad” postures. But these postures vary the tensions and stress’s applied to different tissue. By regularly changing these forces it will allow you to tolerate sitting for longer. Making a conscious effort to change position every 15-20 minutes (remember you can still work, just change position).

Sitting variation

2. Get up and move

Offload the stress and compression of your toxic butt! Giving a chance for tissue to oxygenate and flush unwanted toxins away. Also reducing eye strain, stress levels and fatigue. Not to mention all the other long term health benefits displayed above.

Studies have shown improvements in performance with intermittent breaks every 30 minutes (4). Consider standing when taking a phone call. Think about how many calls you get a day!

3. Sit-standing desks

Standing desks have taken off and are all the rage in open plan offices. Standing gives those stablising muscles a chance to work their magic. But even with standing you should consider regularly changing standing positions to offload pressures. Using a perching stool or foot stool to alternate step-standing.

4. Exercise

If this component is not included all of the above strategies will be wasted. Standing desks are not an exercise, it encourages a little more activity and is more sustainable. But your body needs to be challenged in other positions other than the one you hold most of the day. The long term health benefits are well documented for exercise.

Remember if you are just starting to exercise and coming from prolonged sitting over a number of years, ease into exercise gradually. Start off with regular power walks or exercycle. But as your fitness improves try to challenge it more, through other sources like pilates, yoga, resistance training or team sports.

Sitting isn’t the problem, it’s not moving enough. 

  1. Bell et al, (2014) Combined effect of physical activity and leisure time sitting on long-term risk of incident obesity and metabolic risk factor clustering. Diabetologia
  2. Schmid et al, (2014) Sedentary behavior increases the risk of certain cancers. J Natl Cancer Inst

  3. Katzmarzyk et al, (2012) Sedentary behaviour and life expectancy in the USA: a cause-deleted life table analysis. 
  4. Thorp et al (2014), Breaking up workplace sitting time with intermittent standing bouts improves fatigue and musculoskeletal discomfort in overweight/obese office workers. Occup Environ Med.

Myofascial Release

Myofascia interweaves through our muscles and takes up to 80% of muscle mass. Consider this when you’re doing your stretching and but not getting the results you wanted, it’s possibly due to fascial restrictions.

What is Myofascia?

Fascia is the largest system in the body with the appearance of spider’s web. Fascia is very densely woven from the top of the head to our toes, covering and interpenetrating every muscle, bone, nerve, artery and vein, all our internal organs including the heart, lungs, brain and spinal cord. In this way, you can begin to see that each part of the body is connected to every other part by the fascia, like a fitted suit.

How would it affect me?

Myofascia interweaves through our muscles and takes up to 80% of muscle mass. Consider this when you’re doing your stretching and but not getting the results you wanted, it’s possibly due to fascial restrictions.

I’d like you to try something. Reach behind your back with your right hand, grab a handful of the shirt/top in the middle of your back. Now try and lift your left hand above your head, it will likely be restricted and wind up in certain areas. Think about the tightness and restriction you might feel doing an overhead lift or in the back when squatting, it could be the fascia pulling on these areas.

One study has shown that tightness in the posterior neck muscles can cause a significant decrease in hamstring length and strength. (1)

What causes it to get tight?

Postural adaptations, trauma, inflammatory responses, and surgical procedures create myofascial restrictions that can produce tensile pressures of approximately 2,000 pounds per square inch on pain sensitive structures that do not show up in many of the standard tests (x-rays, MRI scans, etc.)

What does Myofascial release involve?

The MFR technique appears quite light as it puts a slow sustained shearing force on the superficial layer of fascia that lies beneath the skin. The superficial layer taps into other deeper structures within muscle and other systems of the body. There is no oil used as it allows for more feedback detecting for fascial restrictions into the therapist’s hands. There is extensive evidence that shows myofascial release is an effective tool in improving flexibility and reducing pain (2,3,4,5)

How does it differ from a deep tissue massage?

With DTM this is more directed to muscle tissue that has adhesions or is tightened and needs deep pressure to bring back some length and lower its tone. Although the deep pressure can be painful depending on how sensitive the tissue is and pain tolerances of the individual.

 

  1. McPartland et al (1996) Rectus capitis posterior minor: a small but important suboccipital muscle, Journal of Bodywork and Movement Therapies
  2. Hsieh et al,  (2002) Effectiveness of four conservative treatments for subacute low back pain: a randomized clinical trial. Spine.
  3. Wong, K.-K. et al, (2016) Mechanical deformation of posterior thoracolumbar fascia after myofascial release in healthy men – a study of dynamic ultrasound. Physiotherapy
  4. LeBauer et al, (2008) The effect of myofascial release (MFR) on an adult with idiopathic scoliosis. J Bodyw Mov Ther.
  5. Ajimsha et al (2012) Effectiveness of myofascial release in the management of lateral epicondylitis in computer professionals. Arch. Phys. Med. Rehabi.
  6. Ajimsha, M.S. et al, (2014) Effectiveness of Myofascial release in the management of chronic low back pain in nursing professionals Journal of Bodywork and Movement Therapies

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

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