What is the best way to treat low back pain ?

Low back pain is one of the most common, and most complicated problems we see in clinical practice. Everyone from clinicians to patients has their own opinions on the best approach, and looking online reveals a bewildering range of options from Pilates, Yoga, manipulation, massage, Physiotherapy, acupuncture, osteopathy and chiropractic. The list is endless ! In my own time as a clinician i have trained in Spinal manipulation, myofascial release and trigger point acupuncture, Rolfing and literally dozens of exercise techniques to strengthen weak muscles or release others.

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How is one to decide the the best treatment ? Does one choose at random and work through the options (or therapists) until you find the right answer ?

Fortunately we don't have to choose at random. With careful assessment, back pain can be sub-divided into a series of classifications by applying various clinical tests, which have evidence base and are well validated in the scientific literature. For example, the vertebral end plate may sometimes sustain a small fracture, which shows up on MRI and is accompanied by bone bruising (known as modic changes), as shown on the image below:

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A patient presenting in clinic with such a problem, even without the benefit of an MRI to confirm diagnosis, can be diagnosed with the help of careful questioning as to the onset and behaviour of their problem (they frequently report a 'pop' in the back that occurred suddenly in response to lifting). validated clinical tests can confirm the hypothesis. Because this kind of back problem is aggravated by compression, the use of Pilates style spinal stability exercises (which increase compression forces) wouldn't help them, indeed it may make them feel worse ! Anti-inflammatory medication has been shown to delay fracture healing so that wouldn't be a good idea either. Appropriate treatment would go down the lines of suitable analgesia, muscle relaxants such as Diazepam to reduce muscle spasm, and gentle myofascial soft tissue techniques to reduce the compressive forces working on the effected segment. 

Compare this to a patient who also reports lifting reported low back pain, only this time their clinical tests indicate a shearing problem of one vertebral segment on another, usually caused by lax ligaments which have become overstretched. This patient may definitely benefit from Pilates exercises, and soft tissue techniques aimed as 'releasing' muscles are very likely to make them worse !

We could go on and on with these examples, talking about the different ways to diagnose and treat prolapsed discs, trapped nerves, facet joint pain, stenosis etc but i think I've made my point. The start of successful treatment plan begins with an precise diagnosis !

Some thoughts on sports injuries

Annoyingly i seem to have picked up a mild wrist injury. Nothing serious but painful enough to stop me fully participating in my sport of choice - Olympic style weightlifting. There is never a good time to be injured, and it can sometimes lead one to wonder why you bother giving up so much time and training so hard for something, when the rewards are so minimal. Therfore i thought i would share some of my current thoughts on sports injuries, how they may be broadly classified and how to begin thinking about managing them. 

running injury knee

Broadly speaking, sports injuries can generally be classified as either:

  • Over-loading
  • Under capacity 
  • Biomechanical errors
  • Shit happens

Over-loading and over training is common feature of tendon and ligament injuries and stress fractures. These tissues take time to adapt to training, sometimes years. The sudden increases in exercise volume or intensity that frequently occur after Christmas, in spring or the run up to holidays can push them past their capacity and they begin to complain. The key to dealing with this type of problem is to de-load, allow the pain to settle and then gradually build up more intelligently with gradual incremental increase of load, volume and intensity. Reducing the load and conditioning the body so that it is able to tolerate exercise better is the key to managing this type of injury. Seeking the advice of a professional personal trainer or physiotherapist who specialises in sport can also be useful here.

Under capacity of the tissues overlaps with over-loading. In this instance the tendons, ligaments or what have you are just not up to the demands of the activity full stop. The common picture is the middle aged gentleman who decides to return to play 5 a side on a Sunday, hasn't sprinted in years, still thinks he is 21 (we are all still 21 in our heads) and is surprised to learn that his Achilles tendons just aren't up to the job of sprinting across a football pitch. Explosive and dynamic exercise is the culprit here, and the demands upon the tendons are massive. Treatment here consists of dealing with the immediate pain / swelling / dysfunction and developing a progressive loading program to build capacity of the tissues. Seeking the advice of a professional personal trainer or physiotherapist who specialises in sport can also be useful with these first two situations.

Management of Biochemical errors is where physiotherapists really come into their own ! If the cause of your running related knee injury is a pelvic imbalance, then no amount of relative rest or load management will provide a long term solution. We often bumble along with these problems for years, trying to increase running volume for instance but never able to get further than 12 miles because of that blasted iliotibial band pain in the knee ! These conditions need careful assessment and management and are amongst (for me at least) the most rewarding to treat.

Accidents happen. We have good days and bad days. Your running on the fells, you turn your ankle and bang its a sprain. these cant be foreseen. Shit happens. By and large, they will usually get better with the correct acute management.

Now the interesting thing about these four categories of sporting injury is that they frequently occur concurrently, often over a time scale of years. Commonly we see patients with what looks like a simple acute calf tear (file under shit happens), only to find out that have an old hip injury which has left them with residual weakness in the gluteals (biomechanical errors) but they never noticed because they have just decided they are too fat and have started running 3 miles every day (under capacity AND over loading). 

This is where the really interesting work begins.......

Bicep curls are just for gym rats right ?

 The biceps curl, that staple of bro sessions in gyms across the world has (according to many fans of functional training) no more useful function than to give one an impressive set of guns for the beach.  The biceps muscle is composed of two distinct parts with two attachments (Ceps = head). A short head attaching to a tip of bone on the shoulder blade beneath the pecs, and a long head attaching just above the shoulder joint itself.   

The biceps curl, that staple of bro sessions in gyms across the world has (according to many fans of functional training) no more useful function than to give one an impressive set of guns for the beach.

The biceps muscle is composed of two distinct parts with two attachments (Ceps = head). A short head attaching to a tip of bone on the shoulder blade beneath the pecs, and a long head attaching just above the shoulder joint itself.

 

biceps long short heads.jpg

However, a recent study by Chalmars et al (2014) found that the long head of biceps muscle tendon, which crosses the front of the shoulder, was in fact highly active during overhead activities of the shoulder. They theorise that the long head of biceps actually functions as an important shoulder stabiliser and humeral head depressor, assisting the rotator cuff in maintaining the precise balance of shoulder joint position essential for shoulder health. 

Might be worth working on those guns after all !

 

Chalmers, P. N., Cip, J., Trombley, R., Cole, B. J., Wimmer, M. A., Romeo, A. A., & Verma, N. N. (2014). Glenohumeral function of the long head of the biceps muscle: an electromyographic analysis. Orthopaedic journal of sports medicine2(2), 2325967114523902.

Core Strength Training For Cycling - A Case Study

Young Zack Harrup is a local, very promising track, road and mountain biker whose prodigious work ethic impressed me as soon as I met him. His weekly training program is packed with hours of daily training, school and homework, even sleep was highly regimented! He is highly competitive and has a strong desire to win. I think he could go far.

One of the only issues Zack's coaches had picked up on, was that he tended to bob up and down on the bike and that they felt this was reducing his efficiency. They suggested he work on his core stability but didn't really provide much more information than that. It was a chance encounter with his indefatigable mum, Sarah, that brought him to the clinic with the task of addressing this deficit in his training program.

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Following his assessment I picked up significant weaknesses in his glutes and obliques, which were limiting his ability to control his pelvis position on the bike, resulting in reduced ability to express his leg strength. I started Zack on a comprehensive mixture of core stability and functional strength training, with great results - his coaches are reporting a much-reduced tendency to bob up and down on the bike (except for when he's tired) and that he's looking strong. Let's see if he hits any personal bests soon!