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Posts tagged ‘Back pain’

The Fear of Back pain !!

I have already done quite a few blogs on back pain (Part 1, 2 , 3) but the myths surrounding it still continue, so I decided to do one more.

80% of us will probably experience an episode of back pain at one point or another in our life (some studies say that it is even more) (1-3). So, if you think about it, back pain is very common. In fact, to not experience back pain at some point in our life would be quite abnormal. And it doesn´t matter if you have strong or weak abdominals, or if you have too much flexibility or too little, or if one leg is larger than the other, or if you walk in a funny way, none of these factors will influence you experiencing an episode of back pain (4-8). To tell you the truth, the biggest factor for developing back pain is a history of back pain!!! (9). Sounds crazy but it is true.

So, instead of focusing on prevention of back pain (which we have already done for the last 20 years and nothing has changed), maybe we should focus on ¨how do I prevent my back pain from lasting so long¨. You see, when they experience back pain people get really scared, and get fearful of movement, which are two things that can actually make the back pain worse (10-11). Remember, we know the body needs movement to heal. Disk and cartilage etc. need movement to get their blood supply. So in most cases we should try and keep movement. Only when the pain is really bad should we rest but that rest should never be longer than 2 days (12). Pain does not equal tissue damage and it can be influenced by stress, beliefs, fears, anxiety and a thousand other things (as I have stated in previous blogs click here). Our body, including our back, is a wonderful strong machine. We have to start changing our beliefs around the idea that our back can get damaged easily or that our back is vulnerable.

In conclusion, we will all probably experience an episode of back pain in the coming weeks, months, years or whenever, just like we will probably experience a headache or a stomach pain. It is part of life and we shouldn´t get too worried. Studies say that 85-90% percent of the time we have back pain it is due to ¨non specific mechanical factors¨. This basically means we have no IDEA why your back hurts but it does. Only 2% of the time the pain is caused by a tumor, infection or a fracture and 8% due to a nerve compression (13-15). So next time your back hurts don´t be so afraid and keep moving. 😉

References

  1. Biering-Soeren2012 Feb 4;379(9814):482-91. doi: 10.1016/S0140-6736(11)60610-7. Epub 2011 Oct 6.se F. A prospective study of low back pain in a general population. Occurence, recurrence, and etiology. Scand S Rehabilitation Med 1983;19:71.
  2.  Balague F, Mannion AF, Pellise F, Cedraschi. Non-specific low back pain2012 Feb 4;379(9814):482-91. doi: 10.1016/S0140-67
  3. Hashemi L, Webster BS, Clancy EA, Volinn E. Length of disability and cost of workers compensation on low back pain claims. J Occup Environ Med 1998:40:261-66.
  4. Biering-Sorense F. Physical measurements as risk indicators for low-back trouble over a one-year period. Spine, 1984: 9:106-19.
  5. Battie MC, Bigos SJ, Fisher LD, Spengler DM, Hansson TH, Nachemson AL, Wortley MD. The role of spinal flexibility in back pain complaints within industry: A prospective study. Spine 1.
  6. Axler CT, Mcgill SM. Choosing the best abdominal exercises based on knowledge of tissue loads. Medicine and Science in Sports and Exercise. 1997: 29:804-11.
  7. Hellsing AL. Tightness of hamstring and psoas major muscles. Upsala Journal of Medical Science 1988. 93:267-76.
  8. Sandler R, Xuemei Su, TImothy C, Fritz S, Beattie P, Blari S. Are flexibility and muscle-strengthening activities associated with a higher risk of developing low back pain. Journal of Sciend and Medicine in Sporte. 2013.
  9. Taylor JB, Goode AP, George SZ, & Cook CE. Incidence and risk factores for first-time incident low back pain: a systematic review and meta-analysis. Spine Journal 2014
  10. Gheldof EL, Crombez G, Van den Brussche E, et al. Pain related fear predicts disability, but not pain severity: a pathway analytic approach of the fear avoidance model. Eur J Pain.2010;14:870
  11. Awinkkels-Meewisse IE, Roelofs J, Schouten EG, Verbeek AL, Oostendorp RQ, Vlaeyen JW. Fear of movemen/ re injury predicting chronic disabling low back pain: a prospective inception cohort study. Spine( Phila Pa 1976) 2006;31:658-664.
  12. Deyo RA, Diehl Ak, Rosenthal M. How many days of bed rest for acute low back pain? New England Journal of Medicine 1986;315:1064.
  13. Agency for HEalth Care Policy and Research (AHCPR). Acute low back problems in adults. Clinical Practice Guideline Number 19. Washington DC, US. Government Printing. 1994.
  14. Danish Health Technology Assessment (DIMTA). Manniche C, et al. Low back pain. Frequency Managemente and Prevention from an HAD. Perspective. 1991.
  15. Royal College of General Practioners (ACGP). Clinical Guideline for the management of Acute Low Back Pain. London Royal College of General Practicioner.1999

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Lower back pain part 2: Herniation

In one of my  previews blogs I already talked a little about herniation ( http://sports-diet-pain.blogspot.be/2013/10/abdominal-part-2-how-to-really-train.html), but this one is going to be entirely about it.

People are afraid of  a herniation and whenever they hurt their back they automatically think they have a herniation. So, what they do when they hurt their back is go straight to the doctor. The doctor (hopefully) will do a couple of test on you to see that you don´t have any ¨red flags¨, meaning serious injuries, and he might do an X-ray or an MRI on you. Hopefully, if he is a good doctor and has seen that you don´t have any red flags, he will just reassure you that you don´t have anything serious, tell you to try to keep active, and maybe give you something for the pain. I say ¨keep active¨ because different studies have seen that bed rest worsens the condition. At most, and if the pain is really bad, you could do bed rest for 1 or 2 days but never more than 2 days (1). However, if he is not such a good doctor he will send you to have an X-ray or MRI. Patients with simple back pain and no red flags do not need any diagnostic investigations in the first month of symptoms (2). Now, you may ask yourself why this is bad. This is bad because, as I´ve mentioned before in other blogs, 70% of us possible have a disc herniation, disc degeneration, or some other structural abnormality and are asymptomatic, meaning we have no pain (3). So if we have back pain and the doctor sends us to have an MRI he will probably find something wrong with us, but this is probably not the cause of our pain. So, now we will be mislabeled and potentially be receiving unnecessary treatments, but even worse, now we will think ourself as being ¨sick or having something wrong with us¨. And this will probably lead us to having more pain, more absenteeism (sick leave, time off work), decreased productivity while at work, loss of earning, and having a poorer health status (4) . But anyway, this is beyond the scope of this blog. So let us get back to herniation and how we can prevent it.

In one of my previous blogs, I mentioned that it is almost impossible to herniate yourself without being in full flexion and having a compressive force act over the vertebrae (5). A compressive force can be produced by an external weight, like for example a backpack, or by our own muscle. Every time a muscle contracts it produces a compressive force somewhere in the body, so you don´t even have to be picking up something heavy to herniate yourself. Now this is where I´m going to surprise more than one, when you are sitting down you are basically in flexion, your lower back is bend, this causes the nucleus inside the disc (the disc is made of an annulus and a nucleus, the nucleus is gel-like substance and is surrounded by the annulus) to deform posteriorly. This is why sitting down for a long time is bad, because it stresses the tissues. Human beings were not made to perform repetitive work that emphasizes only a few tissues. Nor were humans designed not to be stressed. Research has established that tissues adapt and remodel in response to load (6-8). Too little activity can be as problematic as too much(9) .So let me give an example for you guys to understand what I have just said:

  • In the 1960s, in a power plant in the USA, operators had to respond to a vigilance buzzer on their desk that went off every 10 minutes. At each buzzer interval they would stand and walk around the control panel making adjustments. There was no history of back trouble. As technology got better, they changed the plant so that workers did not have to get up anymore from their desk every 10 minutes. These workers worked 12 hour shifts but now most of the time they were seating down. Well guess what, back problems increased and they had to hire a consultant to help them with their problem.

So, what I basically want you guys to understand is that too much of anything is bad and sitting down for long periods of time is horrible. So all you have to do is get up once in a while.  I always recommend my clients that at least once an hour they have to stand up. And if you have a boss that won´t let you get up, just tell him, first and foremost to read my blog and second that you are saving him money!!

This was only part 1 of herniation, in part 2 I will talk about things you can do to prevent a herniation.

References

  1. Deyo RA, Diehl Ak, Rosenthal M. How many days of bed rest for acute low back pain? New England Journal of Medicine 1986;315:1064
  2. Liebenson Craig. Rehabilitation of the Spine. A practicioner´s manual. Lippicott Williams & Wilkins 2007. pg 131.
  3. Kim S, Lee Hoo T, Lim Mee S. Prevalence of Disc Degeneration in Asymptomatic Korean Subjects. Part 1: Lumbar Spine. Journal of Korean Neutrosurgical Society 2013 January;53(1): 31-8.
  4. Kendrick D, Fielding K, Bentler E, Kerslake R, Miller P, Pringle M. Radiography of the lumbar spine in primary care patients with low back pain: Randomized controlled trial. BMJ 2001;322:400-05.
  5. McGil S. Low Back Disorders 2nd Edition. Human Kinetics 2007 pg 45.
  6. Carter DR. Biomechanics of bone. In: Nahum HM, Melvin J. Biomechanics of trauma. Norwalk, CT: Appleton Century Crofts.
  7. Porter RW. Is hard work good for the back? The relationship between hard work and low back pain-related disorders. International Journal of Industrial Egonomics 1992;9:157-60.
  8. Woo Y, Gomez MA, Akeson WH. Mechanical behaviors of soft tissues: Measurements, modifications, injuries, and treatment. In: Nahum HM, Melvin J. Biomechanics of trauma (pg 109-33). Norwalk, CT:Appleton Century Crofts.
  9. McGill S. Low Back Disorders 2nd Edition. Human Kinetics 2007 pg 153.
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Lower back pain

I don´t want to sound negative or anything, but most of you who will read this blog will, or already have had, an episode of lower back pain. To be exact and according to different studies, low back pain affects 80% of the population at one time or another in their life. Just so that you get a sense of how big lower back pain is I will mention some statistics:

  1. It is the 2nd most common reason for seeing a physician/doctor.
  2. It is the 2nd most common reason for disability, 100 million lost work days a year (1)!!
  3. It is also tremendously expensive, 100 billion dollars are spent each year treating this problem (2-3)!

So seeing its importance, I think we should talk about it a bit and try to dismantle some myths about it. First, I want people to understand that lower back pain can usually be classified into 3 different groups:

  • First red flags: These are caused by serious disease such as a tumor, infection or a fracture. Less than 2% of the people who have lower back pain, have it because of ¨red flags¨(4-6).
  • Second-Nerve compression: This affects less than 10% of the people who get back pain. An example of this could be sciatica.
  • Third Non specific mechanical factors: This basically means we have no IDEA why your back hurts and around 85-90% of the cases fall into this third class (4-6).

So, if you take into account what I just told you, less than 15% of the patients who have lower back pain (LBP) can be given a precise pathoanatomical diagnosis!! The other 85% are sometimes labeled with general terms such as sprain/strain or ¨non-specific¨, in other words they don´t know why your back hurts. The ¨good¨ thing about lower back pain is that it usually has a favorable natural history, meaning that only 5% of the patients with lower back pain will go on to have chronic lower back pain while the rest will (more or less) recover.

Ok, now that we know a bit about what lower back pain is and how it is classified, let´s start talking about some of the myths that exist out there on LBP.

  1. First myth and probably one that you have all heard at one point or another. Strengthen muscles in torso (back) or abdomen to prevent LBP. Until today there has been NO study that has demonstrated this. What has been demonstrated is that ENDURANCE and not strength is a key factor in preventing LBP (7).
  2. Second myth: performing sit-ups or crunches will increase back health. I already talked about this in my blog (here is a link to where you can read it https://sports-diet-pain.com/2013/10/18/abdominal-part-2/), but just to summarize: no one should be performing sit-ups (8).
  3. Third myth: Tight hamstrings lead to back trouble. This is false, there is no study that demonstrates this. What can lead to back trouble is asymmetry, meaning if you have more flexibility in one leg compared to another (7-10). Also, some studies have shown that the more flexibility one has in the back, the greater the risk of having future back troubles, at least in ¨normal people¨. This doesn´t mean that people should not stretch, mobility is important and so is flexibility but too much can maybe lead to back trouble.
  4. Fourth myth: If you sit straight or on a Pilates ball you will prevent back troubles. First I want people to understand that there is no such thing as an IDEAL sitting posture. Tissue loads must be migrated from tissue to tissue to decrease the risk of any single tissue´s accumulating microtrauma. This is accomplished by changing posture. Even the ideal posture, where they tell you to adjust the chair so that the hips and knees are bent 90 degrees and the torso is upright, is only ideal for about 10 minutes. After 10 minutes tissues deform and the best thing to do is change posture again. So let me repeat this again, THERE IS NO SUCH THING AS AN IDEAL SITTING POSTURE, the best thing is to change posture every 10 minutes (11).
  5. Fifth myth: To avoid back injury when lifting, bend the knees not the back. This is partly right but also partly wrong, because to bend your knees or your back depends on a lot of things. Like the dimensions and properties of the load, the characteristics of the lifter, the number of times the lift is to be repeated, and so forth, and there may in fact be safer techniques altogether. Let´s use an example of a golfer, imagine every time he has to pick up a golf ball he has to squat, meaning bend his knees. Ok, maybe his back wouldn´t get hurt but his knees are sure going to hurt after 18 holes of play. So, to keep a straight back would be ideal but in most cases this is not REALISTIC. What you should always avoid when picking things up is a fully flexed spine.

I could go on with more myths but I think those are the most important. So it´s time to move and start talking about factors that we can do to prevent low back pain, but before this I will first talk about herniation. What exactly is a herniation? Is it really that bad, and how do we avoid herniation. This and more in my next blog. Until then.

References

  1. Biering-Soerense F. A prospective study of low back pain in a general population. Occurence, recurrence, and etiology. Scand S Rehabilitation Med 1983;19:71.
  2. Cats-Banil WL, Frymoyer JW. Demographic factors associated with the prevalence of disability in the general population. Analysis of the NHANER I data base. Spine 1991;16:671-71.
  3. Hashemi L, Webster BS, Clancy EA, Volinn E. Length of disability and cost of workers compensation on low back pain claims. J Occup Environ Med 1998:40:261-66.
  4. Agency for HEalth Care Policy and Research (AHCPR). Acute low back problems in adults. Clinical Practice Guideline Number 19. Washington DC, US. Government Printing. 1994.
  5. Danish Health Technology Assessment (DIMTA). Manniche C, et al. Low back pain. Frequency Managemente and Prevention from an HAD. Perspective. 1991.
  6. Royal College of General Practioners (ACGP). Clinical Guideline for the management of Acute Low Back Pain. London Royal College of General Practicioner.1999.
  7. Biering-Sorense F. Physical measurements as risk indicators for low-back trouble over a one-year period. Spine, 1984: 9:106-19.
  8. Battie MC, Bigos SJ, Fisher LD, Spengler DM, Hansson TH, Nachemson AL, Wortley MD. The role of spinal flexibility in back pain complaints within industry: A prospective study. Spine 1.
  9. Axler CT, Mcgill SM. Choosing the best abdominal exercises based on knowledge of tissue loads. Medicine and Science in Sports and Exercise. 1997: 29:804-11.
  10. Hellsing AL. Tightness of hamstring and psoas major muscles. Upsala Journal of Medical Science 1988. 93:267-76.
  11. Callaghan J, McGill S. Low back joint loading and kinematic during standing and unsopported sitting. Ergonomic 2001 :44(3):280-94.
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Pain part 3

So we have talked already about how pain is produced in the brain, how posture really doesn´t affect pain and how pain can be divided into acute and chronic pain. Acute pain being pain that last 3 to 6 moths and chronic pain, pain that last more than 6 months. So how do you treat the different kinds of pain?

With acute pain it is usually quite easy, the pain is associated with the tissue injury that has been produced and, in many cases, pain medications do work reasonably well. For example, NSAIDs (Nosteroidal anti-inflammatory drugs) have been shown to be effective for injuries (like ankle sprain), and after surgery. But for chronic pain, medications are only slightly effective and this is due to the fact that pain can change your nervous system (1,2).

It has always been said that the brain and the nervous system couldn´t change. But since a decade ago we know that the brain is plastic and can indeed change, it´s called NEUROPLASTICITY. Scientists have seen from imaging and animal studies that persistent pain or pain which last for months and years can change the pain pathway, in other words we become more sensitive. This hypersensitivity causes the brain to interpret anything related to those tissues to be highly threatening. So basically the nervous system and the brain have become more efficient in producing and maintaining pain (3-5). You could say that in chronic pain, the pain has moved up to the nervous system and now has very little to do with the initial damage to the tissues that caused the pain.

Let´s try to clear this up and make it easier to understand with an example: John, age 45, has had lower back pain for the last 2 years. Everytime he bends down to pick up something he experiences pain, so he stops doing that. We know that tissues or bones usually heal in between 3 to 6 moths, so there is really nothing wrong with him from a anatomical point of view. And everytime he bends down it doesn´t mean that he got hurt again or that he re-injured himself. It is just that Johns brain and nervous system have become so good at constructing pain that the slightest of triggers – even those that don´t cause damage, cause pain. So how do we deal with this?

The most important thing would be to educate John about pain, to teach him the role of the brain in pain, and to explain to him that pain doesn´t always equal to damage. When education about pain physiology is included into physiotherapy treatment of patients with chronic pain, pain and disability are reduced (6,7). After this, the next thing would be to gradually expose John to the feared activity (bending down) without causing pain and thereby lowering the threat level in the brain. So we would teach him first how to bend down correctly and to only bend till the point before the pain starts. This process would start to decentralize his pain and eventually make his pain disappear.

To finish I want to hopefully think that people now understand a little bit more of how pain acts and how to deal with pain. These last 3 articles have been difficult and maybe hard to understand but I would be satisfied if people took at least these 3 points home:

  1. Damage does not equal pain; not all damage leads to pain, and not all pain is caused by damage. Example: a study in the journal Arthritis & Rheumatism looked at the relationship between knee osteoarthritis and pain (8). They found out that some people had little arthritis and high pain, and some people had severe arthritis but low pain. The researchers concluded that the level of knee pain was due to central sensitization, rather than the level of osteoarthritis. In other words, the level of pain had more to do with changes in their nervous system, not changes in their knee structure.
  2. You can have a bulged disc or degenerated spine, maybe even impinging on one of your nerves, and still not have pain. Or you could have none of these problems, and still have persistent pain (9-12).
  3. The International Association for the Study of Pain defines pain as an emotion. That is, pain is a perception rather than a sensation. Unless and until the brain senses danger or threat, nothing can cause pain.

To finish I will post 2 links.

In one of them Lorimer Moseley describes how to explain pain to patients and in the second one, which is quite long (44 minutes), he talks about the whole process of pain. Enjoy

http://www.youtube.com/watch?v=jIsF8CXouk8

http://www.youtube.com/watch?v=-3NmTE-fJSo

In my next blog we will change the topic drastically and talk about food. Is food a drug?? Can you get addicted to food? We will see and explain in my next blog. See you then.

Bibliography

1. Ekman EF, Ruoff G, Kuehl K, Ralph L, Hombrey P, Fiechtner J, Berger MF. THe COX-2 sècific inhibitor Valdecoxib versus tramadol in acute ankle sprain: a multicenter randomized, controlled trial. Am J Sports Med. 2006 JUn;34(6):945-55. Epub 2006 Feb 13. PubMed PMID: 16476920

2. Buvanendaran A, Kroin JS, Tuman KJ, Lubenow TR, Elmofty D, Moric M, Rosenberg AG. Effects of perioperative administration of a selective cyclooxygenase 2 inhibitor on pain management and recovery of cuntion after knee replacement a randomized controlled trial. JAMA. 2003 Nov 12,290(18):2411-8. PubMEd PMID: 14612477.

3.Flor H, Nikolajse Li, Stachelin Jensen T. Phantom limb pain: a case of maladaptive CNS plasticity.

Nat Rev Neuroscience 2006 Nov;7(11):873-81.

4. Flor H, Braum C, Elber T, BIlbaumer N. Extensive reorganization of primary somatosensory cortex in chronic back pain patients. Neuroscience 1997: March 7.224(1)5-8.

5. Ren K, Dubner R. Central nervous system plasticity and persistent pain. J Orofac. Pain.1999.Summer.13(3):155-63.

6.Moseley GL, Nicholas MK, Hodges PW. A randomized controlled trial of intensive neurophysiology education in chronic low back pain. Clin J pain 2004. Sept 20(5): 324-30.

7. Moseley GL. Widespread brain activity during an abdominal task markedly reduced after pain physiology education: fMRI evaluation of a single patient with chronic low back pain. Aust J Physiotherapy 2005: 31(1):49-52.

8.Dallinga JM, Benjaminse A, Lemmink KA. Which screening tools can predict injury to the lower extremities in team sports?: a systematic review. Sports Med. 2012 Sep 1;42(9):791-815.

9. Johnson C. Modernized Chiropractic reconsidered: beyond foot-on-hose and bones-out-of-place. J Manipulative Physiol Ther. 2006 May;29(4):253-4. PubMed PMID:

10. Ernst E. Chiropractic: a critical evaluation. J Pain Symptom Manage. 2008 May;35(5):544-62. Epub 2008 Feb 14. Review.

11. Homola S. Chiropractic: history and overview of theories and methods. Clin Orthop Relat Res. 2006 Mar;444:236-42.

12. Good CJ. The great subluxation debate: a centrist’s perspective. J Chiropr Humanit. 2010 Dec;17(1):33-9. Epub 2010 Sep 21.

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