The Sydney Morning Herald
Thousands of back pain sufferers given ‘harmful’ treatments
By Liam Mannix
21 March 2018 — 7:29pm
Hundreds of thousands of Australian back pain sufferers are being given harmful or useless treatments, leading researchers say, prompting them to make an extraordinary plea to protect the public.
Thirty-one of the world’s leading back pain researchers have published a call to action in medical journal The Lancet saying lower back pain is being mistreated on an enormous scale.
Professor Rachelle Buchbinder (centre) with Associate Professor Manuela Ferreira and Professor Chris Maher. The trio is leading a global call to action on back pain treatment.
Professor Rachelle Buchbinder (centre) with Associate Professor Manuela Ferreira and Professor Chris Maher. The trio is leading a global call to action on back pain treatment.
Photo: Eddie Jim
Doctors regularly prescribe addictive opioids and potentially harmful treatments including spinal fusion surgery, despite there being little evidence these treatments work, they say.
Meanwhile, cheap treatments that do work are rarely prescribed.
“The elephant in the room is vested interests – among industry but also clinicians,” says Professor Rachelle Buchbinder, lead author of the editorial and an academic at Monash University and the Cabrini Institute.
“Clinicians want to do the best for their patients. But they often believe in treatments even when the evidence shows they don’t work.”
Lower back pain is the leading cause of disability worldwide. One in two Australians experienced it in the past month; globally more than half a billion people were affected last year.
Nearly all cases have no specific cause. “We still don’t know why there are so many sufferers,” Professor Buchbinder says.
Some risk factors are known: obesity, inactivity, a job involving heavy labour. The condition has a significant mental component; disliking your job and depression are other strong risk factors.
Medicos lobby patients for dozens of different and often conflicting treatments. “The poor patient doesn’t know who to believe,” says Professor Buchbinder.
Despite limited evidence of their efficacy, most back pain treatments are funded by Medicare, costing taxpayers about $4.8 billion a year. Treatments proven to work – like yoga – are not subsidised.
“We waste billions. People are being treated with too much of the wrong stuff and missing out on the right stuff,” says Professor Chris Maher, a world-leading back pain expert based at the University of Sydney who co-authored a study on treatment published alongside the editorial.
“We have an industry that’s essentially allowed to do as it pleases in terms of marketing unproved products. People can make billions of dollars marketing something that’s unproven.”
Royal Australasian College of Surgeons spokesman Dr John Quinn said it was “almost certain” the medical industry influenced surgical decisions.
“But we cannot control what individual surgeons do in any given situation. It’s up to them to diagnose and treat their patients as they see fit.”
The best treatments happen to be the cheapest: exercise therapy and psychology. Above all, simply staying active when your back hurts is the best medicine.
“Lower back pain is like the common cold – it should just be considered a part of everyday life,” says Professor Buchbinder. “Most people with back pain, it gets better very quickly whatever you do.”
Robert Joseph has lived with back pain all his adult life after an injury hauling batteries as a young engineer almost 40 years ago.
A year ago, the 60-year-old had a serious flare-up. Struggling to walk, he went to Professor Buchbinder, seeking painkillers.
“She refused to prescribe them,” he says, laughing. “’What you’ve got to do’, she said, ‘is get out of bed and start walking around the house’.
“I said ‘Not a chance in hell’. But she said ‘You can’t injure your back from just walking around’.
“So I started walking around, bent over like a 100-year-old man, and then slowly it just kind of came good.”
Copyright © 2018
Core Treatment Plan Recommendations: This is what the most up to date research tells us.
•Clinicians should educate patients as an adjunct to other treatment. No standardized form of education is suggested [Strong Recommendation, Moderate Quality Evidence].
•Non-steroidal anti-inflammatory drugs (NSAIDs) may be used for short-term pain relief in patients with acute and subacute low back pain [Weak Recommendation, Moderate Quality Evidence].
•Muscle relaxants may be used as an option in treating acute low back pain. However, possible side effects should be considered [Weak Recommendation, Moderate Quality Evidence].
•Cautious and responsible use of opioids may be considered for those carefully selected patients with severe acute pain not controlled with acetaminophen and NSAIDs, at a minimum effective dose, for a limited period of time, usually less than one to two weeks [Strong Recommendation, Low Quality Evidence].
•Heat should be used for pain relief [Strong Recommendation, Moderate Quality Evidence]. •Cold therapy is not recommended for low back pain [Weak Recommendation, Low Quality Evidence].
•Clinicians should advise patients with acute and subacute low back pain to stay active and continue activities of daily living within the limits permitted by their symptoms [Strong Recommendation, Moderate Quality Evidence].
•Exercise should be recommended to reduce the recurrence of low back pain. However, no specific exercise is preferred [Strong Recommendation, Moderate Quality Evidence].
•Clinicians should not recommend bed rest for patients with low back pain [Strong Recommendation, Moderate Quality Evidence].
•Clinicians should not prescribe or recommend traction for the treatment of acute low back pain [Weak Recommendation, Low Quality Evidence].
•Clinicians should not recommend imaging (including computed tomography [CT], magnetic resonance imaging [MRI], and x-ray) for patients with non-specific low back pain [Strong Recommendation, Moderate Quality Evidence].
The core treatment plan addresses the need for patient education, reassurance and expectations. Patient satisfaction is dependent on a clear diagnosis with information and instructions on how to handle their low back pain. A care plan should include the following: •Answers to questions addressed by the patient. In general, this should include discussion of causation and the natural history of low back pain. It may need to include reasons for not ordering tests such as laboratory or imaging. •Instructions on pain and activity management. Include positional and exercise components as well as work recommendations or limitations. •Instructions on treatment recommendations including medications and/or therapy recommendations. •Follow-up and contact information in response to desire for further reassurance or education, and descriptions of specific warning signs, which may require earlier evaluation.
Provide patients with brochures and information that place a greater emphasis on reducing fear and anxiety, promote active self-management and incorporate the following components of care. See Appendix C, “Patient Brochure Example,” in the original guideline document.
There is a good prognosis for low back pain. The majority of patients experience significant improvements in two to four weeks. Most patients who seek attention for their back pain will improve within two weeks and most experience significant improvement within four weeks.
Approximately two-thirds of the people who recover from a first episode of acute low back symptoms will have another episode within 12 months. Unless the back symptoms are very different from the first episode or the patient has a new medical condition, expect improvement to be similar for each episode.
All patients recovering from back pain should understand that episodes of back pain may recur but can be handled similarly to the one from which they are recovering.
Clinicians in clinic systems are encouraged to provide primary education through other community education institutions/businesses to develop and make available patient education materials concerning back pain prevention and care of the healthy back. Emphasis should be on patient responsibility, workplace ergonomics, and home self-care treatment of acute low back pain. Employer groups should also make available reasonable accommodations for modified duties or activities to allow early return to work and minimize the risk of prolonged disability. Education is recommended for frontline supervisors in occupational strategies to facilitate an early return to work and to prevent prolonged disabilities. Identify and manage stressors.
Acetaminophen and Non-steroidal Anti-inflammatory Medication
All medications have potential benefits and risks that patients should be aware of. Short-term use of medications (less than two weeks) may reduce some of the risks.
Use over-the-counter short-term acetaminophen or non-steroidal anti-inflammatory drugs (NSAIDs) to help ease the pain and/or inflammation in the lower back. Patients need to be aware that all NSAIDs have a risk of gastritis and gastrointestinal bleed, and possible cardiovascular implications. Acetaminophen has the risk of serious liver disease.
Muscle relaxants may be useful for short-term relief of acute low back pain. The use of muscle relaxants is an option that needs to be weighed against the possible side effects and contraindications.
Cautious and Responsible Use of Opioids
The consensus opinion of the work group is that the cautious and responsible use of opioids for severe acute and subacute low back pain in carefully selected patients, for limited periods of time (usually less than one to two weeks) may be considered. Clinicians may consider using low potency opioids, using the lowest daily dose possible. Extended release opioids should be avoided if possible in acute back pain patients, especially in opioid naïve patients. Clinicians should always assess risk before ordering opioids. Risk to the patient, but also to the community, should be considered. Opioids should be used only as one part of a comprehensive care plan for the patient with acute and subacute low back pain.
Apply heat as preferred on the sore area for a short duration in a position of comfort to assist with pain management. Cold therapy is not recommended.
Encourage Activity; Bed Rest Is Not Recommended
Carefully introduce activities as the patient begins to recover from the worst of the back pain episode. Light-duty activities and regular walking are good ways to get back into action. Participate in activity that does not worsen symptoms. Advise to stay active and to continue ordinary activity as normally as tolerated to give faster return to work, less chronic disability and fewer recurrent problems. Patients should also be provided information about effective self-care options. Exercise over no intervention is useful for reducing the rate of low back pain recurrence. Bed rest is not recommended. A gradual return to normal activities is more effective and leads to more rapid improvement with less chronic disability.
Refer to the original guideline document for more information on the above topics and for information about addressing fear-avoidance beliefs (fear of activity) and return-to-work assessment.
The use of imaging including CT, MRI and x-ray is not recommended for non-specific low back pain.
Reassess as Needed
Instruct the patient to return for the following reasons: •Pain that doesn’t seem to be getting better after two to three weeks •Pain and weakness traveling down the leg below the knee •Leg, foot, groin or rectal area feeling numb •Unexplained fever, nausea/vomiting, stomachaches, weakness or sweating •Loss of control of urine or stool •Pain is so intense you can’t move around or get comfortable •Redness or swelling on the back or spine •Desire for further reassurance or education
Early Acute Phase Treatment Considerations
Recommendations in this phase include those found in Annotation #11, “Core Treatment Plan,” in addition to the following: •Spinal manipulative therapy should be considered in the early intervention of low back pain [Strong Recommendation, Moderate Quality Evidence]. •At this point evidence is not sufficient to strongly recommend the clinical prediction rule. However, studies are currently underway which may add further support. Therefore, the work group suggests consideration of the clinical prediction rule in the category of early low back pain patients [Weak Recommendation, Low Quality Evidence].
For those patients who are seen within the first two weeks from onset of symptoms and have severe pain or physical impairment, the following approaches are recommended:
Consider Spinal Manipulative Therapy: Use Clinical Prediction Rule
The clinical prediction rule is used to identify a subgroup of patients by several criteria (see Table 2, “Clinical Prediction Rule,” in the original guideline document). The rule projects successful treatment of low back pain with spinal manipulative therapy at greater than 90%. Although much work has been done related to the clinical prediction rule, at this point, evidence is not sufficient to strongly recommend it. However, studies currently underway may add further support. Therefore, the work group suggests consideration of this rule in this category of early low back pain patients.
Late Acute Phase Treatment Consideration
Recommendations in this phase include those found in Annotation #11, “Core Treatment Plan,” in addition to the following: •Delayed-recovery assessment is not fully developed; however, much progress has been made and it is recommended that the clinician use one or more approaches to identify a patient who is at risk and intervene with specific interventions [Weak Recommendation, Low Quality Evidence].
Core Treatment Plan
Incorporate core treatment plan into plan of care. See Annotation #11, “Core Treatment Plan,” for more information.
If the patient presents with low back pain symptoms for two to six weeks of severe limits in function and/or severe pain, add the following care to the core treatment plan.
Focused Review of Treatment to Date
Complete a focused review of treatment to date to determine successes and failures in treatment modalities thus far.
Because the majority of acute low back pain sufferers improve within the first two weeks from onset, it is difficult to identify before this time the 10% to 15% who will experience chronic pain or disability. The period from two to six weeks is a key time to assess for risk factors and if possible, to begin approaches to manage them. Though progress has been made over the last 20 years, this is still an imprecise process. The chart in the original guideline document (page 24) describes three approaches – structured self report, open questions and observation – that can be used to assess risk. Each approach can increase focus and in many situations trigger an intervention plan to address the risk early in the continuum of disability and pain.
Individual risk factors with stronger predictive ability include the following:
•Fear-avoidance beliefs •Catastrophizing •Somatization •Depressed mood •Distress and anxiety •Early disability or decreased function •High initial pain levels •Increased age •Radiation of pain •Poor general health status •Non-organic signs
Subacute Phase Treatment Consideration
Recommendations in this phase include those found in Annotation #11, “Core Treatment Plan,” in addition to the following:
- Delayed-recovery risk assessment is not fully developed; however, much progress has been made and it is recommended that the clinician use one or more approaches to identify a patient who is at risk and intervene with specific interventions [Weak Recommendation, Low Quality Evidence].
- Exercise is recommended in the treatment of subacute low back pain [Strong Recommendation, Moderate Quality Evidence].
- Spinal manipulative therapy should be considered in the early intervention of low back pain [Strong Recommendation, Moderate Quality Evidence].
- Clinicians should consider cognitive behavioral therapy in the treatment of subacute low back pain [Weak Recommendation, Moderate Quality Evidence].
- Acupuncture may be used as an adjunct treatment for subacute low back pain [Weak Recommendation, Low Quality Evidence].
Progressive Exercise Plan
The use of a progressive exercise program in the treatment of subacute low back pain is supported. Progressive exercise is based on a number of variables that include but are not limited to increasing physical activity, education regarding pain and an exercise program that is graded with a de-emphasis on pain.
We believe in sharing the most up to date evidence. This evidence was provided by the Agency for Healthcare research and quality.
Common Soccer Injuries
As a dynamic, high speed game where physical contact occurs both incidentally and deliberately, soccer creates many circumstances where injury may result. Most soccer injuries are relatively minor in terms of the degree of disability created; more serious injuries often result through the execution of a hard sliding tackle or other sudden physical collisions between players. Data from researchers regarding soccer injuries indicates that there are over 150,000 soccer injuries reported annually in the United States, among a playing population of over three million athletes; approximately 45% of these injuries occur in players under the age of 15 years.
As would be expected in a sport that centers on kicking a ball, injuries to the lower legs are the most common injuries in soccer. Ankle sprains are another common occurrence, often created by either an awkward plant of one of the feet while running or changing direction, or by stepping on another player’s foot, causing the ankle to twist forcefully. Most soccer players wear a cleat that is low cut to permit greater maneuverability, and this footwear is not naturally supportive of the ankle.
The Achilles tendon is vulnerable to two kinds of injury. Given the explosive movement required of a soccer player, the Achilles must instantly respond to the impulses of musculoskeletal movement. If the Achilles tendon is imbalanced in terms of either its strength relative to the connected muscles of the calf, or if the tendon is not sufficiently flexible, the fibers of the tendon can become overstretched or subjected to micro tears. The second type of injury to the Achilles results from the tendon being kicked from behind by an opposing player. The resulting trauma can significantly damage the tendon fibers.
Soccer players are subjected to numerous varieties of accidental kicks from an opponent in the course of play. Most of these kicks result only in contusions, as the players wear relatively durable shin guards. More serious injuries to the lower leg may occur as a result of a defender’s sliding tackle, where the defender slides forcefully along the turf to strip the ball from an opponent. If the tackle is not executed cleanly, the offensive player’s leg may be caught and twisted, the mechanics necessary for either a significant ankle sprain or a fracture of the tibia/fibula bones in the lower shin.
The knee can also be injured by a sliding tackle, if the offensive player’s leg is planted on impact and the knee joint is forced laterally (sideways); this type of collision prevents any of the force of impact being directed and absorbed anywhere but the knee joint. In such circumstances, the anterior cruciate ligament (ACL), a large connective tissue between the femur and the tibia in the knee joint, is at the greatest risk of injury. Other knee injuries occur in the same fashion as ankle injuries, where the leg is planted forcefully on an uneven surface, and the ultimate stress radiates directly into the knee.
Thigh injuries in soccer are typically one of two types. The first are contusions, as the thigh is exposed to all manner of physical contact in the course of a game. The second type of injuries are those common to all other running sports, muscle strains and pulls caused by repetitive and often explosive acceleration. Soccer players who have an imbalance in the function of the hamstring, which provides flexion to the knee, and that of the quadriceps, which gives the knee its ability to extend, will often experience injuries to these muscle and tendon groups.
Groin injuries are often the bane of the high-level soccer player. The structure of muscles, tendons, and ligaments in the upper thighs and the lower abdomen is complex; these tissues are also vulnerable to injury in soccer due to the almost constant lateral and stop and start movements that place stress on them. The abdominal injury that has attracted attention throughout the sports world that is popularly called a sports hernia is, in fact, a tear of the groin inguinal hernia, first identified among English professional soccer players in 1980. Such injuries require surgical repair.
Other than contusions, injuries to the upper body in soccer are less common. The collisions in the sport will occasionally cause a shoulder separation, which is damage to the acromioclavicular (AC) joint, the connection between the shoulder blade and the collarbone. Soccer goalies are more exposed to shoulder injury as a result of diving across the crease to make saves and striking the goal post.
Head injuries may occasionally arise due to collisions with opponents—concussion and damage to the player’s teeth are the greatest risk. Many players wear mouth guards to protect their teeth, which has the additional benefit of reducing the effect of concussions by keeping the tempomandibular joint (TMJ) from being driven upward into the skull. Since the mid-1990s, there has been controversy in the international sports science community as to whether the repeated heading of a soccer ball will cause damage to the brain or to the muscles and structure of the neck. Various studies initiated by soccer nations have not yet resolved this question.
If you suffer from back pain, you are far from being alone. Four out of five adults experience the symptoms of low back pain at least once in their lifetime. The back is a complex structure made up of 33 vertebrae, over 30 muscles, numerous ligaments, multiple joints, and inter-vertebral discs. As you can see, there are many structures that can cause discomfort if injured or affected.
The most common cause of back pain is due to muscular strains. This happens when an unexpected force, twist, or pull is applied to one or several of the muscles in the back. As a result, several tears occur in the muscle. These muscular tears cause pain felt in the back.
Ligamentous sprains are another common cause of back pain. This occurs when the ligaments of the back are stretched beyond their means. Sprains often occur along with muscular strains.
Herniated discs result in back pain by compressing the spinal nerves where they exit the spinal column. They are often the result of repetitive vibratory motion (as experienced by truck drivers/machine users) or due to a sudden heavy loading of the back (as occurs with improper lifting) This injury results in a radicular type of back pain in which pain is felt at the site of injury and along the course of the affected nerve. Sciatica, for example, is a type of radicular pain.
Spinal stenosis is another cause of back pain. It occurs more commonly in people over 50 years old. The term refers to a narrowing of the spinal canal. Spinal stenosis has many causes including thickened ligaments along the spinal canal, bony spurs, and enlarged joint cartilage from arthritic changes. This condition often results in back pain that is worse with extended periods of weight bearing or walking. Surgery is sometimes necessary to correct this disorder.
Osteoarthritis affects the joints of the spine. As with spinal stenosis, it found more commonly in people over 50 years of age. It is often referred to as degenerative joint disease. With time cartilage starts to degenerate in the discs between our vertebrae and in the joints of our spine. Without this cartilaginous cushion, our bones begin to rub against each other. This results in inflammation, swelling and stiffness that in turn cause back pain. As this disorder progresses bones develop spurs and ligaments become thick, both of which result in spinal stenosis as described above.
Osteoporosis is a common cause of back pain especially in women. It is a disease characterized by progressive loss of bone density. This results in thinning of bone tissue making one more susceptible to fractures, or broken bones. The bones of the spine are especially affected in this disorder. Injury from falls, lifting of heavy objects, or even the force of sneezing can result in painful vertebral compression fractures.
Lastly, fibromyalgia is a common cause of chronic back pain. It is a rheumatic condition characterized by widespread soft tissue pain, fatigue, sleep disturbance, and the presence of evenly distributed areas of tenderness. A history of at least three months of widespread pain and tenderness in eleven or more of the eighteen designated tender point sites is required in diagnosing this disorder.
If you have lower back pain, you are not alone. Nearly everyone at some point has back pain that interferes with work, routine daily activities, or recreation. Americans spend at least $50 billion each year on low back pain, the most common cause of job-related disability and a leading contributor to missed work. Back pain is the second most common neurological ailment in the United States — only headache is more common. Fortunately, most occurrences of low back pain go away within a few days. Others take much longer to resolve or lead to more serious conditions.
Acute or short-term low back pain generally lasts from a few days to a few weeks. Most acute back pain is mechanical in nature — the result of trauma to the lower back or a disorder such as arthritis. Pain from trauma may be caused by a sports injury, work around the house or in the garden, or a sudden jolt such as a car accident or other stress on spinal bones and tissues. Symptoms may range from muscle ache to shooting or stabbing pain, limited flexibility and/or range of motion, or an inability to stand straight. Occasionally, pain felt in one part of the body may “radiate” from a disorder or injury elsewhere in the body. Some acute pain syndromes can become more serious if left untreated.
Chronic back pain is measured by duration — pain that persists for more than 3 months is considered chronic. It is often progressive and the cause can be difficult to determine.
What structures make up the back?
The back is an intricate structure of bones, muscles, and other tissues that form the posterior part of the body’s trunk, from the neck to the pelvis. The centerpiece is the spinal column, which not only supports the upper body’s weight but houses and protects the spinal cord — the delicate nervous system structure that carries signals that control the body’s movements and convey its sensations. Stacked on top of one another are more than 30 bones — the vertebrae — that form the spinal column, also known as the spine. Each of these bones contains a roundish hole that, when stacked in register with all the others, creates a channel that surrounds the spinal cord. The spinal cord descends from the base of the brain and extends in the adult to just below the rib cage. Small nerves (“roots”) enter and emerge from the spinal cord through spaces between the vertebrae. Because the bones of the spinal column continue growing long after the spinal cord reaches its full length in early childhood, the nerve roots to the lower back and legs extend many inches down the spinal column before exiting. This large bundle of nerve roots was dubbed by early anatomists as the cauda equina, or horse’s tail. The spaces between the vertebrae are maintained by round, spongy pads of cartilage called intervertebral discs that allow for flexibility in the lower back and act much like shock absorbers throughout the spinal column to cushion the bones as the body moves. Bands of tissue known as ligaments and tendons hold the vertebrae in place and attach the muscles to the spinal column.
Starting at the top, the spine has four regions:
- the seven cervical or neck vertebrae (labeled C1 – C7),
- the 12 thoracic or upper back vertebrae (labeled T1 – T12),
- the five lumbar vertebrae (labeled L1 – L5), which we know as the lower back, and
- the sacrum and coccyx, a group of bones fused together at the base of the spine.
The lumbar region of the back, where most back pain is felt, supports the weight of the upper body.
What causes lower back pain?
As people age, bone strength and muscle elasticity and tone tend to decrease. The discs begin to lose fluid and flexibility, which decreases their ability to cushion the vertebrae.
Pain can occur when, for example, someone lifts something too heavy or overstretches, causing a sprain, strain, or spasm in one of the muscles or ligaments in the back. If the spine becomes overly strained or compressed, a disc may rupture or bulge outward. This rupture may put pressure on one of the more than 50 nerves rooted to the spinal cord that control body movements and transmit signals from the body to the brain. When these nerve roots become compressed or irritated, back pain results.
Low back pain may reflect nerve or muscle irritation or bone lesions. Most low back pain follows injury or trauma to the back, but pain may also be caused by degenerative conditions such as arthritis or disc disease, osteoporosis or other bone diseases, viral infections, irritation to joints and discs, or congenital abnormalities in the spine. Obesity, smoking, weight gain during pregnancy, stress, poor physical condition, posture inappropriate for the activity being performed, and poor sleeping position also may contribute to low back pain. Additionally, scar tissue created when the injured back heals itself does not have the strength or flexibility of normal tissue. Buildup of scar tissue from repeated injuries eventually weakens the back and can lead to more serious injury.
Occasionally, low back pain may indicate a more serious medical problem. Pain accompanied by fever or loss of bowel or bladder control, pain when coughing, and progressive weakness in the legs may indicate a pinched nerve or other serious condition. People with diabetes may have severe back pain or pain radiating down the leg related to neuropathy. People with these symptoms should contact a doctor immediately to help prevent permanent damage.
Who is most likely to develop low back pain?
Nearly everyone has low back pain sometime. Men and women are equally affected. It occurs most often between ages 30 and 50, due in part to the aging process but also as a result of sedentary life styles with too little (sometimes punctuated by too much) exercise. The risk of experiencing low back pain from disc disease or spinal degeneration increases with age.
Low back pain unrelated to injury or other known cause is unusual in pre-teen children. However, a backpack overloaded with schoolbooks and supplies can quickly strain the back and cause muscle fatigue. The U.S. Consumer Product Safety Commission estimates that more than 13,260 injuries related to backpacks were treated at doctors’ offices, clinics, and emergency rooms in the year 2000. To avoid back strain, children carrying backpacks should bend both knees when lifting heavy packs, visit their locker or desk between classes to lighten loads or replace books, or purchase a backpack or airline tote on wheels.
What conditions are associated with low back pain?
Conditions that may cause low back pain and require treatment by a physician or other health specialist include:
Bulging disc (also called protruding, herniated, or ruptured disc). The intervertebral discs are under constant pressure. As discs degenerate and weaken, cartilage can bulge or be pushed into the space containing the spinal cord or a nerve root, causing pain. Studies have shown that most herniated discs occur in the lower, lumbar portion of the spinal column.
A much more serious complication of a ruptured disc is cauda equina syndrome, which occurs when disc material is pushed into the spinal canal and compresses the bundle of lumbar and sacral nerve roots. Permanent neurological damage may result if this syndrome is left untreated.
Sciatica is a condition in which a herniated or ruptured disc presses on the sciatic nerve, the large nerve that extends down the spinal column to its exit point in the pelvis and carries nerve fibers to the leg. This compression causes shock-like or burning low back pain combined with pain through the buttocks and down one leg to below the knee, occasionally reaching the foot. In the most extreme cases, when the nerve is pinched between the disc and an adjacent bone, the symptoms involve not pain but numbness and some loss of motor control over the leg due to interruption of nerve signaling. The condition may also be caused by a tumor, cyst, metastatic disease, or degeneration of the sciatic nerve root.
Spinal degeneration from disc wear and tear can lead to a narrowing of the spinal canal. A person with spinal degeneration may experience stiffness in the back upon awakening or may feel pain after walking or standing for a long time.
Spinal stenosis related to congenital narrowing of the bony canal predisposes some people to pain related to disc disease.
Osteoporosis is a metabolic bone disease marked by progressive decrease in bone density and strength. Fracture of brittle, porous bones in the spine and hips results when the body fails to produce new bone and/or absorbs too much existing bone. Women are four times more likely than men to develop osteoporosis. Caucasian women of northern European heritage are at the highest risk of developing the condition.
Skeletal irregularities produce strain on the vertebrae and supporting muscles, tendons, ligaments, and tissues supported by spinal column. These irregularities include scoliosis, a curving of the spine to the side; kyphosis, in which the normal curve of the upper back is severely rounded; lordosis, an abnormally accentuated arch in the lower back; back extension, a bending backward of the spine; and back flexion, in which the spine bends forward.
Fibromyalgia is a chronic disorder characterized by widespread musculoskeletal pain, fatigue, and multiple “tender points,” particularly in the neck, spine, shoulders, and hips. Additional symptoms may include sleep disturbances, morning stiffness, and anxiety.
Spondylitis refers to chronic back pain and stiffness caused by a severe infection to or inflammation of the spinal joints. Other painful inflammations in the lower back include osteomyelitis (infection in the bones of the spine) and sacroiliitis (inflammation in the sacroiliac joints).
How is low back pain diagnosed?
A thorough medical history and physical exam can usually identify any dangerous conditions or family history that may be associated with the pain. The patient describes the onset, site, and severity of the pain; duration of symptoms and any limitations in movement; and history of previous episodes or any health conditions that might be related to the pain. The physician will examine the back and conduct neurologic tests to determine the cause of pain and appropriate treatment. Blood tests may also be ordered. Imaging tests may be necessary to diagnose tumors or other possible sources of the pain.
A variety of diagnostic methods are available to confirm the cause of low back pain:
X-ray imaging includes conventional and enhanced methods that can help diagnose the cause and site of back pain. A conventional x-ray, often the first imaging technique used, looks for broken bones or an injured vertebra. A technician passes a concentrated beam of low-dose ionized radiation through the back and takes pictures that, within minutes, clearly show the bony structure and any vertebral misalignment or fractures. Tissue masses such as injured muscles and ligaments or painful conditions such as a bulging disc are not visible on conventional x-rays. This fast, noninvasive, painless procedure is usually performed in a doctor’s office or at a clinic.
Discography involves the injection of a special contrast dye into a spinal disc thought to be causing low back pain. The dye outlines the damaged areas on x-rays taken following the injection. This procedure is often suggested for patients who are considering lumbar surgery or whose pain has not responded to conventional treatments. Myelograms also enhance the diagnostic imaging of an x-ray. In this procedure, the contrast dye is injected into the spinal canal, allowing spinal cord and nerve compression caused by herniated discs or fractures to be seen on an x-ray.
Computerized tomography (CT) is a quick and painless process used when disc rupture, spinal stenosis, or damage to vertebrae is suspected as a cause of low back pain. X-rays are passed through the body at various angles and are detected by a computerized scanner to produce two-dimensional slices (1 mm each) of internal structures of the back. This diagnostic exam is generally conducted at an imaging center or hospital.
Magnetic resonance imaging (MRI) is used to evaluate the lumbar region for bone degeneration or injury or disease in tissues and nerves, muscles, ligaments, and blood vessels. MRI scanning equipment creates a magnetic field around the body strong enough to temporarily realign water molecules in the tissues. Radio waves are then passed through the body to detect the “relaxation” of the molecules back to a random alignment and trigger a resonance signal at different angles within the body. A computer processes this resonance into either a three-dimensional picture or a two-dimensional “slice” of the tissue being scanned, and differentiates between bone, soft tissues and fluid-filled spaces by their water content and structural properties. This noninvasive procedure is often used to identify a condition requiring prompt surgical treatment.
Electrodiagnostic procedures include electromyography (EMG), nerve conduction studies, and evoked potential (EP) studies. EMG assesses the electrical activity in a nerve and can detect if muscle weakness results from injury or a problem with the nerves that control the muscles. Very fine needles are inserted in muscles to measure electrical activity transmitted from the brain or spinal cord to a particular area of the body. With nerve conduction studies the doctor uses two sets of electrodes (similar to those used during an electrocardiogram) that are placed on the skin over the muscles. The first set gives the patient a mild shock to stimulate the nerve that runs to a particular muscle. The second set of electrodes is used to make a recording of the nerve’s electrical signals, and from this information the doctor can determine if there is nerve damage. EP tests also involve two sets of electrodes — one set to stimulate a sensory nerve and the other set on the scalp to record the speed of nerve signal transmissions to the brain.
Bone scans are used to diagnose and monitor infection, fracture, or disorders in the bone. A small amount of radioactive material is injected into the bloodstream and will collect in the bones, particularly in areas with some abnormality. Scanner-generated images are sent to a computer to identify specific areas of irregular bone metabolism or abnormal blood flow, as well as to measure levels of joint disease.
Thermography involves the use of infrared sensing devices to measure small temperature changes between the two sides of the body or the temperature of a specific organ. Thermography may be used to detect the presence or absence of nerve root compression.
Ultrasound imaging, also called ultrasound scanning or sonography, uses high-frequency sound waves to obtain images inside the body. The sound wave echoes are recorded and displayed as a real-time visual image. Ultrasound imaging can show tears in ligaments, muscles, tendons, and other soft tissue masses in the back.
How is back pain treated?
Most low back pain can be treated without surgery. Treatment involves using analgesics, reducing inflammation, restoring proper function and strength to the back, and preventing recurrence of the injury. Most patients with back pain recover without residual functional loss. Patients should contact a doctor if there is not a noticeable reduction in pain and inflammation after 72 hours of self-care.
Although ice and heat (the use of cold and hot compresses) have never been scientifically proven to quickly resolve low back injury, compresses may help reduce pain and inflammation and allow greater mobility for some individuals. As soon as possible following trauma, patients should apply a cold pack or a cold compress (such as a bag of ice or bag of frozen vegetables wrapped in a towel) to the tender spot several times a day for up to 20 minutes. After 2 to 3 days of cold treatment, they should then apply heat (such as a heating lamp or hot pad) for brief periods to relax muscles and increase blood flow. Warm baths may also help relax muscles. Patients should avoid sleeping on a heating pad, which can cause burns and lead to additional tissue damage.
Bed rest — 1–2 days at most. A 1996 Finnish study found that persons who continued their activities without bed rest following onset of low back pain appeared to have better back flexibility than those who rested in bed for a week. Other studies suggest that bed rest alone may make back pain worse and can lead to secondary complications such as depression, decreased muscle tone, and blood clots in the legs. Patients should resume activities as soon as possible. At night or during rest, patients should lie on one side, with a pillow between the knees (some doctors suggest resting on the back and putting a pillow beneath the knees).
Exercise may be the most effective way to speed recovery from low back pain and help strengthen back and abdominal muscles. Maintaining and building muscle strength is particularly important for persons with skeletal irregularities. Doctors and physical therapists can provide a list of gentle exercises that help keep muscles moving and speed the recovery process. A routine of back-healthy activities may include stretching exercises, swimming, walking, and movement therapy to improve coordination and develop proper posture and muscle balance. Yoga is another way to gently stretch muscles and ease pain. Any mild discomfort felt at the start of these exercises should disappear as muscles become stronger. But if pain is more than mild and lasts more than 15 minutes during exercise, patients should stop exercising and contact a doctor.
Medications are often used to treat acute and chronic low back pain. Effective pain relief may involve a combination of prescription drugs and over-the-counter remedies. Patients should always check with a doctor before taking drugs for pain relief. Certain medicines, even those sold over the counter, are unsafe during pregnancy, may conflict with other medications, may cause side effects including drowsiness, or may lead to liver damage.
- Over-the-counter analgesics, including nonsteroidal anti-inflammatory drugs (aspirin, naproxen, and ibuprofen), are taken orally to reduce stiffness, swelling, and inflammation and to ease mild to moderate low back pain. Counter-irritants applied topically to the skin as a cream or spray stimulate the nerve endings in the skin to provide feelings of warmth or cold and dull the sense of pain. Topical analgesics can also reduce inflammation and stimulate blood flow. Many of these compounds contain salicylates, the same ingredient found in oral pain medications containing aspirin.
- Anticonvulsants — drugs primarily used to treat seizures — may be useful in treating certain types of nerve pain and may also be prescribed with analgesics.
- Some antidepressants, particularly tricyclic antidepressants such as amitriptyline and desipramine, have been shown to relieve pain (independent of their effect on depression) and assist with sleep. Antidepressants alter levels of brain chemicals to elevate mood and dull pain signals. Many of the new antidepressants, such as the selective serotonin reuptake inhibitors, are being studied for their effectiveness in pain relief.
- Opioids such as codeine, oxycodone, hydrocodone, and morphine are often prescribed to manage severe acute and chronic back pain but should be used only for a short period of time and under a physician’s supervision. Side effects can include drowsiness, decreased reaction time, impaired judgment, and potential for addiction. Many specialists are convinced that chronic use of these drugs is detrimental to the back pain patient, adding to depression and even increasing pain.
Spinal manipulation is literally a “hands-on” approach in which professionally licensed specialists (doctors of chiropractic care) use leverage and a series of exercises to adjust spinal structures and restore back mobility.
When back pain does not respond to more conventional approaches, patients may consider the following options:
Acupuncture involves the insertion of needles the width of a human hair along precise points throughout the body. Practitioners believe this process triggers the release of naturally occurring painkilling molecules called peptides and keeps the body’s normal flow of energy unblocked. Clinical studies are measuring the effectiveness of acupuncture in comparison to more conventional procedures in the treatment of acute low back pain.
Biofeedback is used to treat many acute pain problems, most notably back pain and headache. Using a special electronic machine, the patient is trained to become aware of, to follow, and to gain control over certain bodily functions, including muscle tension, heart rate, and skin temperature (by controlling local blood flow patterns). The patient can then learn to effect a change in his or her response to pain, for example, by using relaxation techniques. Biofeedback is often used in combination with other treatment methods, generally without side effects.
Interventional therapy can ease chronic pain by blocking nerve conduction between specific areas of the body and the brain. Approaches range from injections of local anesthetics, steroids, or narcotics into affected soft tissues, joints, or nerve roots to more complex nerve blocks and spinal cord stimulation. When extreme pain is involved, low doses of drugs may be administered by catheter directly into the spinal cord. Chronic use of steroid injections may lead to increased functional impairment.
Traction involves the use of weights to apply constant or intermittent force to gradually “pull” the skeletal structure into better alignment. Traction is not recommended for treating acute low back symptoms.
Transcutaneous electrical nerve stimulation (TENS) is administered by a battery-powered device that sends mild electric pulses along nerve fibers to block pain signals to the brain. Small electrodes placed on the skin at or near the site of pain generate nerve impulses that block incoming pain signals from the peripheral nerves. TENS may also help stimulate the brain’s production of endorphins (chemicals that have pain-relieving properties).
Ultrasound is a noninvasive therapy used to warm the body’s internal tissues, which causes muscles to relax. Sound waves pass through the skin and into the injured muscles and other soft tissues.
Minimally invasive outpatient treatments to seal fractures of the vertebrae caused by osteoporosis include vertebroplasty and kyphoplasty. Vertebroplasty uses three-dimensional imaging to help a doctor guide a fine needle into the vertebral body. A glue-like epoxy is injected, which quickly hardens to stabilize and strengthen the bone and provide immediate pain relief. In kyphoplasty, prior to injecting the epoxy, a special balloon is inserted and gently inflated to restore height to the bone and reduce spinal deformity.
In the most serious cases, when the condition does not respond to other therapies, surgery may relieve pain caused by back problems or serious musculoskeletal injuries. Some surgical procedures may be performed in a doctor’s office under local anesthesia, while others require hospitalization. It may be months following surgery before the patient is fully healed, and he or she may suffer permanent loss of flexibility. Since invasive back surgery is not always successful, it should be performed only in patients with progressive neurologic disease or damage to the peripheral nerves.
- Discectomy is one of the more common ways to remove pressure on a nerve root from a bulging disc or bone spur. During the procedure the surgeon takes out a small piece of the lamina (the arched bony roof of the spinal canal) to remove the obstruction below.
- Foraminotomy is an operation that “cleans out” or enlarges the bony hole (foramen) where a nerve root exits the spinal canal. Bulging discs or joints thickened with age can cause narrowing of the space through which the spinal nerve exits and can press on the nerve, resulting in pain, numbness, and weakness in an arm or leg. Small pieces of bone over the nerve are removed through a small slit, allowing the surgeon to cut away the blockage and relieve the pressure on the nerve.
- IntraDiscal Electrothermal Therapy (IDET) uses thermal energy to treat pain resulting from a cracked or bulging spinal disc. A special needle is inserted via a catheter into the disc and heated to a high temperature for up to 20 minutes. The heat thickens and seals the disc wall and reduces inner disc bulge and irritation of the spinal nerve.
- Nucleoplasty, also called plasma disc decompression (PDD), uses radiofrequency energy to treat patients with low back pain from contained, or mildly herniated, discs. Using x-ray guidance, a special needle is inserted into the disc. A wand-like device is inserted into the needle and heated between 40 and 70 degrees Celsius to create a plasma field that removes a small portion of the tissue and seals the channel. Several channels may be made depending on how tissue needs to be removed to decompress the disc and nerve root.
- Radiofrequency lesioning is a procedure using electrical impulses to interrupt nerve conduction (including the conduction of pain signals) for 6 to12 months. Using x-ray guidance, a special needle is inserted into nerve tissue in the affected area. Tissue surrounding the needle tip is heated for 90-120 seconds, resulting in localized destruction of the nerves.
- Spinal fusion is used to strengthen the spine and prevent painful movements. The spinal disc(s) between two or more vertebrae is removed and the adjacent vertebrae are “fused” by bone grafts and/or metal devices secured by screws. Spinal fusion may result in some loss of flexibility in the spine and requires a long recovery period to allow the bone grafts to grow and fuse the vertebrae together.
- Spinal laminectomy (also known as spinal decompression) involves the removal of the lamina (usually both sides) to increase the size of the spinal canal and relieve pressure on the spinal cord and nerve roots.
Other surgical procedures to relieve severe chronic pain include rhizotomy, in which the nerve root close to where it enters the spinal cord is cut to block nerve transmission and all senses from the area of the body experiencing pain; cordotomy, where bundles of nerve fibers on one or both sides of the spinal cord are intentionally severed to stop the transmission of pain signals to the brain; and dorsal root entry zone operation, or DREZ, in which spinal neurons transmitting the patient’s pain are destroyed surgically.
Can back pain be prevented?
Recurring back pain resulting from improper body mechanics or other nontraumatic causes is often preventable. A combination of exercises that don’t jolt or strain the back, maintaining correct posture, and lifting objects properly can help prevent injuries.
Many work-related injuries are caused or aggravated by stressors such as heavy lifting, contact stress (repeated or constant contact between soft body tissue and a hard or sharp object, such as resting a wrist against the edge of a hard desk or repeated tasks using a hammering motion), vibration, repetitive motion, and awkward posture. Applying ergonomic principles — designing furniture and tools to protect the body from injury — at home and in the workplace can greatly reduce the risk of back injury and help maintain a healthy back. More companies and homebuilders are promoting ergonomically designed tools, products, workstations, and living space to reduce the risk of musculoskeletal injury and pain.
The use of wide elastic belts that can be tightened to “pull in” lumbar and abdominal muscles to prevent low back pain remains controversial. A landmark study of the use of lumbar support or abdominal support belts worn by persons who lift or move merchandise found no evidence that the belts reduce back injury or back pain. The 2-year study, reported by the National Institute for Occupational Safety and Health (NIOSH) in December 2000, found no statistically significant difference in either the incidence of workers’ compensation claims for job-related back injuries or the incidence of self-reported pain among workers who reported they wore back belts daily compared to those workers who reported never using back belts or reported using them only once or twice a month.
Although there have been anecdotal case reports of injury reduction among workers using back belts, many companies that have back belt programs also have training and ergonomic awareness programs. The reported injury reduction may be related to a combination of these or other factors.
Quick tips to a healthier back
Following any period of prolonged inactivity, begin a program of regular low-impact exercises. Speed walking, swimming, or stationary bike riding 30 minutes a day can increase muscle strength and flexibility. Yoga can also help stretch and strengthen muscles and improve posture. Ask your physician or orthopedist for a list of low-impact exercises appropriate for your age and designed to strengthen lower back and abdominal muscles.
- Always stretch before exercise or other strenuous physical activity.
- Don’t slouch when standing or sitting. When standing, keep your weight balanced on your feet. Your back supports weight most easily when curvature is reduced.
- At home or work, make sure your work surface is at a comfortable height for you.
- Sit in a chair with good lumbar support and proper position and height for the task. Keep your shoulders back. Switch sitting positions often and periodically walk around the office or gently stretch muscles to relieve tension. A pillow or rolled-up towel placed behind the small of your back can provide some lumbar support. If you must sit for a long period of time, rest your feet on a low stool or a stack of books.
- Wear comfortable, low-heeled shoes.
- Sleep on your side to reduce any curve in your spine. Always sleep on a firm surface.
- Ask for help when transferring an ill or injured family member from a reclining to a sitting position or when moving the patient from a chair to a bed.
- Don’t try to lift objects too heavy for you. Lift with your knees, pull in your stomach muscles, and keep your head down and in line with your straight back. Keep the object close to your body. Do not twist when lifting.
- Maintain proper nutrition and diet to reduce and prevent excessive weight, especially weight around the waistline that taxes lower back muscles. A diet with sufficient daily intake of calcium, phosphorus, and vitamin D helps to promote new bone growth.
- If you smoke, quit. Smoking reduces blood flow to the lower spine and causes the spinal discs to degenerate.
What research is being done?
The National Institute of Neurological Disorders and Stroke, a component of the National Institutes of Health (NIH) within the U.S. Department of Health and Human Services, is the nation’s leading federal funder of research on disorders of the brain and nervous system and one of the primary NIH components that supports research on pain and pain mechanisms. Other institutes at NIH that support pain research include the National Institute of Dental and Craniofacial Research, the National Cancer Institute, the National Institute on Drug Abuse, the National Institute of Mental Health, the National Center for Complementary and Alternative Medicine, and the National Institute of Arthritis and Musculoskeletal and Skin Diseases. Additionally, other federal organizations, such as the Department of Veterans Affairs and the Centers for Disease Control and Prevention, conduct studies on low back pain
When standing and walking, we are subjected to forces that produce stress and strain throughout our bodies. When a foot imbalance is present there can be abnormal forces on the feet, knees, hips, back and/or neck that lead to pain and poor function. The foot imbalance must be corrected to improve body alignment and therefore, decrease pain and improve function.
What are Custom Orthotics?
Custom orthotics are devices which are inserted into footwear to support or correct your foot function.
When appropriately prescribed, custom orthotics can:
- Decrease pain, not only in the foot, but in other parts of the body such as the knee, hip and lower back.
- Increase stability in an unstable joint.
- Prevent a deformed foot from developing additional problems.
- Improve overall quality of life.
How are custom orthotics made?
While orthotics can be made by several different processes, we take a foam impression of the patient’s foot in a “neutral” position and send it to a laboratory with the physiotherapist’s direction for correction.
At the lab, technicians pour plaster into the mould and, when it hardens, it reproduces the bottom of the individual’s foot. The technicians then use the physiotherapist’s directions to custom-make a device to meet the patient’s specific needs.
Who Can Benefit From Orthotics?
- those in need of relief of painful foot problems or an injury
- people who must walk or stand excessively on the job
- those who are active in sports: orthotics will often increase endurance, performance and strength
- overweight individuals: orthotics can help to counteract the extra stress on the feet, as minor problems are often magnified due to the increased weight
- older adults who may have developed arthritis in their feet: orthotics are particularly effective in relieving foot fatigue and discomfort
- orthotics may also be prescribed for children who have a foot deformity
Types of Custom Orthotics
Different types of custom orthotics are available for different uses. There are a number of sport specific orthotics designed for use in running/walking shoes, ski boots, skates, golf shoes and court shoes. Sandals come with the orthotic built in a way to prevent slippage. Dress shoes generally don’t have much extra space and therefore come with a thinner orthotic. There are also orthotics designed for special health needs such as arthritis and diabetes. Talk to us about what type of custom orthotic would best suit your needs!
Upper back and neck pain
Firstly, I want to be clear as to the type of problem we are talking about. This is an aching pain and muscular tension in the upper back and neck which is not due to a specific injury. It is most common in office and desk based workers and sometimes drivers who are sat in one position for extended periods.
If your neck pain is more severe such as a sharp, stabbing pain on movement or causes neural symptoms like tingling or numbness into the arms or hands then we recommend you seek medical attention. Similarly, if your neck pain has occurred after an initial injury or event such as a car accident or fall, we recommend visiting your Family Doctor or Physical Therapist.
As a sports physio, upper back and neck pain forms a large part of my workload. In fact, I would say that it is the most common problem I see. It is certainly far more common in my clinic than lower back problems, which may come as a surprise to many.
The reason for the vast majority of these problems is poor posture. This is especially true for those who spend their days sat at a desk. To fully understand why poor posture causes upper back and neck pain and how it should be treated, we need to understand the anatomy of the region.
When we refer to the neck we are talking about the cervical spine. This is the uppermost section of the spine which consists of 7 vertebrae, starting with C1 at the base of the skull, down to C7 which can be felt as the bony prominence at the base of the neck.
The main functions of the neck are to support the head and allow us to rotate, tilt and nod the head. The head is surprisingly heavy, weighing in at around 4-5Kg. Just holding this large, heavy orb on top of a relatively thin structure (the neck) is quite a challenge and places a lot of demands on our neck muscles.
There are many small muscles in the neck, deep and close to the spine. These help with small movements and stability. The larger muscles which we can see and feel tend to be the ones which we associate with being ‘tight’ and achey. These muscles almost act as guy ropes on the neck to hold the head upright. They attach to the bony areas around the shoulders such as the scapula and collar bones and course upwards to attach either to the upper C spine or the skull. Examples of these muscles include upper trapezius, levator scapulae, and sternocleidomastoid.
The muscles at the back of the neck are responsible for extending the neck and head (moving it backwards) and many also help rotate and tilt the head. The muscles at the front of the neck perform neck and head flexion (bending the neck forwards) and allow us to nod our heads. Several also help with rotation and tilting.
Poor posture is frequently blamed for numerous injuries and pain problems. I honestly believe there is no injury where this is truer than in the case of upper back and neck pain. In other injuries, there are often other factors and posture is just part of the problem (for example lower back pain). But in this case, it is often the sole issue.
So, what do we mean by poor posture? This is basically anything which varies from the ideal, perfect position. The most common problems for those desk based workers with upper back and neck pain include:
- Retracted scapulae – the shoulder blades tilt and move forwards around the back (away from the spine).
- Excess neck flexion – the neck is bent forwards, often due to straining to see a computer screen.
- Chin poke – this refers to the chin jutting forwards rather than being tucked in.
- Scapula elevation – the shoulders are lifted up, either due to the desk being too high, chair being low or stress causing us to hunch the shoulders.
What happens when these postural positions are maintained for any length of time is that the muscles responsible adapt to make this normal and to reduce the stress placed on them. Muscles in a shortened position (such as the chest muscles and upper fibres of trapezius) become more permanently shortened and ‘tight’. Muscles in a lengthened position often become weak and allow other muscles to do their job. Examples include the deep neck flexors and scapula stabilisors such as lower trapezius and serratus anterior
Neck pain starts to develop in response to certain muscle groups becoming tight and overworked. The most common examples include the upper Trapz, Levator scapulae, Rhomboids, Sternocleidomastoid and Scalenes. The position of the neck may also place stress on additional structures such as the ligaments which support the C spine.
Many people will allow neck pain like this to linger on for a long, long time before they do anything about it. It may only be when other symptoms such as aching or weakness spreading into the arms or tingling in the finger tips develops that they decide enough is enough.
What most people will do is head straight for a massage and blame ‘stress’ for their neck pain. Whilst stress can be a contributing factor, it is rarely the only factor. A relaxing massage might help temporarily; a deep tissue or sports massage may have slightly longer benefits, but in both cases it doesn’t address the cause of the pain and so it will only return.
What both patients and therapists need to address is the muscle imbalances and postural issues which caused the muscle tension in the first place. There are some very simple but effective exercises which can be performed to help correct these imbalances.
Treatment methods such as massage and acupuncture can help to ease muscular tension and stress and contribute to correcting muscle imbalances and treating active trigger points. But they should not be the only form of treatment.
The most important step in treating upper back and neck pain is to understand why you have this pain and what you are doing in order to try and correct it. When you understand this, it makes performing your exercises correctly and remembering about your postural corrections and desk set-up easier.
As touched on in part one, most of these neck pain conditions are due to posture issues and muscle imbalances. The most common scenario is that the patient has rounded shoulders caused by tight chest muscles and weak scapula stabilisors, as well as a forward position of the head, caused by weak deep neck flexors and tight posterior neck muscles.
Postural re-education refers to learning about good posture and applying this to your working position. Whilst simply learning the best position for you, and trying to hold this position may help to ease pain temporarily, it is difficult to do and it may result in different muscular aches and pains due to not correcting the muscle weaknesses responsible for the problem. A rehabilitation programme is needed to correct these imbalances.
As already established the muscle groups which are frequently weak are the scapula stabilisors (Serratus Anterior, lower Trapzius) and the deep neck flexors.
To strengthen the scapular muscles and improve their ability to hold the correct postural position, scapula setting exercises can be used:
- Lie on the front with the arms by the sides and rested on the couch / floor.
- If a breathing hole is not available, a pillow or rolled up towel should be placed under the forehead so that the head is facing straight down and the neck muscles can relax.
- Keeping the neck and arms relaxed, pull the shoulder blades back and together as far as possible. Imagine trying to hold a pencil between the shoulder blades.
- Ease off 50%, relaxing the shoulders back towards the resting position. At the halfway point, hold this position for 10 seconds.
- Ensure the neck muscles stay relaxed throughout.
- Rest and repeat 10 times.
This exercise can be progressed once it is not challenging. The next step is to lift just the hands up off the couch. After this becomes easy, the next step is to lift the whole arms up so they are hovering just an inch from the couch. This adds the weight of the arms into the equation.
To strengthen the deep neck flexor muscles:
- Lie on the back with the knees bent.
- Imagine a rod is passing straight through your skull, out of each of your ears.
- Rotate the head, as if rotating around this rod, tucking the chin into the neck.
- Rotate the skull using your hands (by your ears) for a physical cue if necessary.
- Hold this position for 5 seconds.
- Rest and repeat 10 times.
An additional challenge involves raising the head an inch off the floor once the chin is tucked in. Again hold this for 5 seconds, rest and repeat. Once mastered, this exercise can be performed in an upright position.
Where some muscle groups are weak, their opposite (antagonist) group are tight. In most cases, this is the chest muscles (especially Pectoralis Minor) and the posterior neck muscles such as Trapezius and Levator Scapulae.
Stretching the chest muscles
Stretching the chest muscles can be performed as described here:
- Stand in a doorway, with the upper arm horizontal to the floor and the elbow bent to a right angle (like a stop signal!).
- Place the front of the forearm against the doorframe.
- Lean the body forwards and rotate the body away from the stretching arm, until a stretch is felt in the chest and front of the shoulder.
- Hold for 20-30 seconds, rest and repeat.
To stretch the pec minor more specifically:
- Lie lengthways on a foam roller so the roller goes along the spine.
- Take one arm out to the side and allow it to relax down to the floor.
- Hold this position, whilst allowing the shoulder joints to drop down and towards the floor.
- A small weight such as a wrist or ankle weight or beanbag can be placed on the front of the shoulder to increase the stretch.
- Hold for 60 seconds and repeat on each arm.
To stretch the posterior neck muscles:
- Hold underneath your chair to anchor the shoulder down.
- Bring your chin down to the chest and then take the head over to the side, away from the anchored arm.
- You should feel a stretch between the neck and the shoulder joint.
- Hold for 20-30 seconds, rest and repeat 2-3 times on each side.
Postural Taping can be used in the early stages of treatment to provide proprioceptive feedback about the position of a patient’s shoulders and thoracic spine. Taping tends to be applied from the shoulder blades, over the top of the shoulder to the front. The tape is applied whilst the patient is in an ‘ideal’ postural position with the scapulae retracted and depressed. If the patient strays from this position, the tape pulls on the skin and acts as a reminder.
Soft Tissue Therapy
In part one of this article we commented that many people’s initial response to this form of neck pain is to go for a massage. This can be helpful on a temporary basis when used alone, but if not combined with postural re-education the benefits will be short-lived.
That’s not to say that massage and other forms of soft tissue treatment should not be used. Registered Massage Therapy, trigger point therapy and acupuncture can be very helpful in reducing muscle tension, improving flexibility and de-activating trigger points in the traps, levator scapulae and chest muscles in particular. However, they should form only a small part of the treatment regimen.
This refers to the set-up and positioning of your work space In most cases, this means the chair, desk, screen, keyboard, mouse and telephone. A poor set-up can be a major contributor to upper back and neck pain and to developing and establishing poor postures.
Professional ergonomists are often employed by large companies to ensure their staff have a good office workspace. As well as changing the positions and heights etc of workspace components, they may introduce new items such as wrist supports and foot rests.
Even if this is not normal company practice, if you think your desk set-up may be less than ideal, speak to your boss to see if it is possible to get a professional in to have a look. It may even save them money on sick pay for back pain in the long run!
Here are some key points to look out for:
- Make sure the height of your chair allows you to rest your forearms on the desk when your fingers are on the middle row of the keyboard.
- Your elbows should be supported by the arm rests and the wrists are straight (not arched upwards).
- Your elbows should be directly under your shoulders.
- Keep the mouse as close to you as possible whilst the elbow is supported on the arm rest.
- Use the hand and fingers to move the mouse, not the wrist or arm!
- The top of your computer monitor should be at eye level and directly in front of you.
- Good posture in the upper back and neck starts in the lower back! Ensure you sit with both feet on the floor, with the backs of the thighs on the chair seat and a natural lordotic curve in the lower back (i.e. not slumped).
In conclusion, the treatment approach for posture related upper back and neck pain should be multi-faceted. The main focus should be on correcting muscle imbalances through exercise rehabilitation and looking at desk set-up to address additional aggravators. Massage can play a role in treatment, but should not be used as the one and only form of therapy.
We are proud to offer Running Assessments to our community on the Saanich Peninsula and runners in Brentwood Bay, Sidney, and Victoria. Our Physiotherapist Scott Simpson has worked with our National Track and Field team internationally and has taken numerous courses in this area. He is also a former Canadian 10k Champion who has spent years learning and enjoying the sport.
Session One: Initial Clinical Evaluation
This session includes:
- Injury and running history information forms:
Information pertaining to all the factors that may have an influence on current or possible future injuries.
- One-on-one interview:
A detailed and in-depth personal interview to discuss current problems, past injuries, medical history, present running level and goals.
- Physical assessment:
To identify your physical alignment and any factors that could limit or contribute to your running biomechanics, including: range of motion, muscular imbalances, skeletal alignment, posture, and flexibility.
Session Two: Running Evaluation
This session includes:
- Biomechanical and Technical assessment:
As running is a highly technical sport, your movement patterns and technique will be assessed first and corrections implemented.
The biomechanical evaluation focuses on assessing joint integrity, balance, strength and flexibility throughout run and stride.
Following the on track assessment, recommendations are made to maximize your running and minimize your risk of injury or pain. A personalized detailed training plan including training modifications, stretches, exercises and technique drills will be included.
- Eliminate reoccurring hip pain
- Decrease foot numbness and pain
- Ensure you’re doing everything you can to have a successful training and/or marathon experience
- Learn if you’re wearing the correct running shoe
- Learn strengthening and flexibility exercises to remain injury free
- Learn exercises to stabilize ankles, knees and hips
- Get ideas for injury prevention
- Receive advise and solutions for reoccurring injuries
- Run longer distances without discomfort
- Learn about running orthotics and if an orthotic could assist you in remaining injury free
- Find out if your current orthotic is suitable for running
- Receive running form analysis to improve your stride
- Resume running and return to your marathon training program
- Determine how to proceed running without constant pain/stiffness
- Learn if your previous knee surgery will cause other problems if you continue to run
- Biomechanical analysis for your knees to feel better
See the Big Picture. Treat the CAUSE of injury.
This is the ‘hands-on’ of physiotherapy which is found at the Saanichton Physiotherapy and Sports Clinic. Although there are certain improvements that can be made by stretching and massage alone, sometimes a more specific technique is required to mobilize or manipulate joints that don’t move properly. Often Manual Therapy can help minimize the likelihood of major injury by looking at the big picture. We treat the CAUSE and not just the SYMPTOM. After such a treatment, you may be shown home exercises that can be done to keep your joints functioning well.
What types of Manual & Manipulative Therapy can Physiotherapists provide?
Joint mobilization – a skilled passive slow movement applied by the therapist to the affected joint to improve its range of motion. This can be applied to any joint, from the jaw all the way to the toes.
Joint manipulation – a skilled passive fast movement applied by the therapist to a stiff joint. There is usually a characteristic ‘pop’ sound or feeling. These can be applied to most joints of the body. Manipulations of the spine itself are limited to those professionals with advanced training in this area, including physiotherapists.
Back and neck pain are among the most widespread reasons patients seek physiotherapy. And back pain is one of the most common medical problems, affecting 80% of people at some point during their lives. Back pain can range from a dull, constant ache to a sudden, sharp pain, and can be acute or chronic. Neck pain, which is closely associated with back pain, occurs when muscles are strained from poor posture or injury, or when joints are worn or nerves are compressed. Both conditions can be debilitating and effect a patient’s physical and mental wellbeing.
Early access to physiotherapy (within 14 days of occurrence) has a significant long-term impact on the health of patients as it helps to prevent chronic disability and decreases the proportion of cases that become chronic.
So, if you suffer from back or neck pain, seeking the guidance of a physiotherapist is a great first step towards finding pain relief and keeping you moving for life.
Vary your position. Sitting at computers and desks all day puts increased pressured on your spine. After 30 minutes of sitting make sure you walk around to keep the flow of blood and fluids to your spine. Set up a standing workstation to vary your position while working at your computer. Make sure your work desk and computer are set up properly for sitting or standing to encourage optimal posture. Your physiotherapist will prescribe suitable and safe stretches or “pause exercises” and provide tips on how to correctly position yourself in front of your computer.
Stay flexible. Optimal spinal health means having flexibility in all directions. If your thorax (upper-mid back and ribcage) has limited rotation movement, more load and stress can be transferred to your low back, neck or other body parts. Check your rotation by sitting in a chair with your arms crossed across your stomach; you should be able to turn equally to the right and left and see behind you easily. If you have an asymmetry between the right and left directions, or reduced motion, your physiotherapist can assess the reason why, mobilize your spinal joints, and give you exercises to maintain your thoracic mobility – essential for a healthy low back and neck.
Keep your core in check. Regain optimal control of your deep spinal muscles (core) following an episode of neck or back pain. Your physiotherapist will provide a thorough examination of your spine, provide manual therapy and other treatment techniques, and help you regain any lost mobility by instructing you on how to achieve ideal postural alignment and prescribing exercises that will support your spine.
Correct postural habits. Be aware of habitual postures and positions (such as always sitting on one side of the couch, slouching with your feet on the coffee table, carrying your bag/purse always over the same shoulder, sitting cross legged, leaning usually on the same elbow etc.) Habitually poor postures may indicate weaknesses in certain muscle groups or stiffness within the body. Your physiotherapist can assess reasons why you may adopt these positions and how to correct them.
Physiotherapists are the rehabilitation specialists recommended most by physicians. They are university-educated health professionals who work with patients of all ages to diagnose and treat virtually any mobility issue. Physiotherapists provide care for orthopedic issues such as sport and workplace injuries, as well as cardiorespiratory and neurological conditions. As Canada’s most physically active health professionals, BC’s physiotherapists know how to keep British Columbians moving for life.
Sports Injuries in Young Children: Tips for Caregivers
Here are some “on-the-field” tips for helping a young child who has been injured:
•Minor injuries are fairly common in young children; severe injuries are not.
•A young child’s self-esteem and enjoyment of a sport can be influenced by an adult’s reaction when the child is injured.
•Judging the intensity and finding the site of the pain in a preschool child may not be easy. The child’s perception of severity, influenced by his/her temperament and developmental level, may not match reality. The child’s response to an injury may also reflect his/her prior experiences or the experiences of a friend or family member who has had an injury.
•Don’t judge a child’s reaction to an injury based on the child’s age, sex, or size. Young children may vary greatly in their physical and mental development, temperaments, and reactions to and tolerance of pain and stress.
•Acknowledge the child’s feelings (pain, fright, and/or anxiety), provide emotional support, and convey a sense of protection and caring.
•Treat children with respect. Never ridicule or belittle them in front of their peers, as this may be harmful to their developing self-esteem. Reassure the child that he/she will be cared for and the injury will be evaluated.
•Inappropriate overconcern can have negative effects and may lead to a more frightened child or eventually to a more vulnerable child. Parents may have difficulty remaining objective about their child’s injury. On the other hand, parental knowledge of their child’s temperament and typical reaction to pain can be immensely helpful to others trying to evaluate the severity of the injury.
•Question the child simply and directly. An authoritative approach, gentle but firm, will be reassuring for some youngsters.
•Listen to the injured youngster and get his/her reaction to reentering a sport or activity. Sometimes hidden fears will be expressed that can be addressed by a caregiver who listens. A child’s mental health and development are as important as his/her physical health.
•Time, ice, and a caring attitude will help to minimize many simple traumatic injuries.