Our spinal columns are made of twenty four vertebrae stacked one above another on the pelvis. They are joined together at the front by discs and at the back by facet joints. When we bend forward, the vertebra above tilts and slides forward, compressing the disc and stretching the facet joints at the back of the vertebrae. When we bend backward, the disc compression is reduced at the front and the facet joints are compressed at the back. In the upper neck and thoracic areas we tend to have more facet joint strains and in the lower cervical spine and lumbar spine areas, disc injuries are more frequent. This is because our upper spine joints allow us to turn our heads to see, hear and smell, so they need mobility but do not support much weight. Our lumbar spine bears around half our body weight and as we move and sit, there are huge, sustained, compressive loads on our discs.
CAUSES OF BACK PAIN
Disc injuries are the most common cause of low back pain and can range in severity from a mild intermittent ache, to a severe pain where people cannot move. Disc injuries occur mainly during sudden loading such as when lifting, or during repetitive or prolonged bending forces such as when slouching, rowing, hockey and while cycling. They are often aggravated by coughing and running. A flexed posture during slouching, bending or lifting is a frequent cause of disc damage because of the huge leverage and compression forces caused by gravity pulling down on the mass of the upper body.
It is important to understand that damage from small disc injuries is cumulative if discs are damaged at a faster rate than they can heal and the damage will eventually increase until it becomes painful. Pain sensing nerves are only on the outside of the disc, so by the time there is even small pain of disc origin, the disc is already significantly damaged internally where there are no nerve endings to feel pain with.
There may be a previous history of pain coming and going as the damaged area has become inflamed, perhaps was rested or treated, settled for a while but as the underlying problem was not fixed, the pain has flared up repeatedly since. This type of disc injury responds very well to Physiotherapy treatment.
A marked disc injury causes the outer disc to bulge, stretching the outer disc nerves. In a more serious injury, the central disc gel known as the nucleus, can break through the outer disc and is known as a disc bulge, prolapse or extrusion.
Spinal muscles are often blamed as the cause of spinal pain but this is rarely the cause of the pain. Muscle pain may develop as the muscles contract to prevent further damage as they protect the primary underlying painful structures. This muscle pain is secondary to the underlying pathology and when the muscles are massaged, given acupuncture etc, there is temporary relief but the pain will often come back, as the muscles resume their protective bracing. Treatment must improve the structure and function in the tissues which the muscles are trying to protect. The most common sources of primary pain are the discs, facet joints and their ligaments.
There are four facet joints at the back of each vertebra, two attaching to the vertebra above and two attaching to the vertebra below. A facet joint strain is much like an ankle sprain and the joints can be strained by excessive stretching or compressive forces. The joint ligaments, joint lining and even the joint surfaces can be damaged and will then produce pain.
Facet joint sprains can occur during excessive bending but typically occur with backward, lifting or twisting movements. Trauma such as during a car accident or during repetitive or prolonged forces such as when slouching or bowling at cricket.
There are many other sources of back pain including arthritis, crush fractures and various disease processes. Your Physiotherapist will examine your back and advise you should further investigation be necessary.
SYMPTOMS OF BACK PAIN
Symptoms of structural back pain are always affected by movement. This is important to understand. Symptoms, usually pain but perhaps tingling and pins and needles, are often intense and may be sudden in onset but also may be mild and of gradual onset. There are other conditions which can produce back pain such as abdominal problems, ovarian cysts and intestinal issues. If you have symptoms in these areas which are not affected by movement, you must consult with your doctor. If you have chest, jaw or upper limb pain which is unaffected by movement, you must attend your doctor or hospital immediately.
Facet joints, discs, muscles and other structures are affected by our positions and movements. More minor problems produce central low back pain. With more damage, the pain may spread to both sides and with nerve irritation, the pain may spread down into the thigh or leg. As a general rule, disc pain is worse with bending, lifting and slouching and facet joint strains are worse twisting and bending backward or sideways. A severe disc problem is often worse with coughing or sneezing and on waking in the morning.
DIAGNOSIS OF BACK PAIN
Diagnosis of back injuries is complex and requires a full understanding of the onset history and a comprehensive physical examination. It is important for your Physiotherapist to establish a specific and accurate diagnosis to direct the choice of treatment. In some cases, the pain may arise from several tissues known as co-existing pathologies and each of these are treated as they are identified. Where the Physiotherapist requires further information or the management may require injections or surgery, the appropriate x-rays, scans and a referral will be arranged.
UPPER BACK AND LOWER BACK PAIN RELIEF
Eighty percent of adults will experience severe spinal pain at some time in their life. Much of this pain is called non-specific low back pain and is treated with generic non-specific treatment. This type of treatment often fails to provide lasting relief. However, Musculoskeletal Physiotherapists have developed specific diagnostic skills and specific treatment techniques, targeted to specific structures. We identify the structure and cause of the pain producing damage and develop specific advice and strategies to prevent further damage and promote healing.
Specific techniques are chosen to correct the structural and mechanical problems. Among many choices, treatment may include joint mobilisation, stretching, ice, strengthening and education. As normal tissue structure and function returns, there is a reduction in the inflammation and the pain will subside.
When normal movement has been achieved, the inflammation has settled and the structures have healed, your new strategies will reduce the possibility of the problem recurring. We use this specific approach to reduce or stop chronic pain.
While we have the choice to manipulate, adjust or click joints, patients with ongoing pain will seldom benefit from repeating these techniques. This is because our tissues are elastic and the benefit of the quick stretch of manipulation is lost, as the elastic tissues tighten and shorten again. Adjustments of this type have little long term benefit and often lead to an unhealthy dependence on the provider. Your Physiotherapist will choose a safer and more appropriate treatment for you.
PROGNOSIS OF BACK PAIN
Physiotherapy for back pain can provide outstanding results but it is a process, not magic. The damage which produces pain in a back takes time to develop and also time to repair and heal. You will understand there are often several interacting factors to deal with and patient compliance is necessary.
Millions of people take opioids for chronic back pain, but many of them get limited relief while experiencing side effects and worrying about the stigma associated with taking them.
More than 100 million people in the United States suffer from chronic pain, and those with chronic low back pain are more likely than patients with other types of pain to be prescribed opioids. Unfortunately, these medications are addictive and can cause side effects, ranging from drowsiness to breathing problems.
“Patients are increasingly aware that opioids are problematic, but don’t know there are alternative treatment options,” said Asokumar Buvanendran, M.D., lead author of the study, director of orthopedic anesthesia and vice chair for research at Rush University, Chicago, and vice chair of the American Society of Anesthesiologists (ASA) Committee on Pain Medicine. “While some patients may benefit from opioids for severe pain for a few days after an injury, physicians need to wean their patients off them and use multi-modal therapies instead.”
In the study, 2,030 people with low back pain completed a survey about treatment. Nearly half (941) were currently taking opioids. When asked how successful the opioids were at relieving their pain, only 13 percent said “very successful.” The most common answer — given by 44 percent — was “somewhat successful” and 31 percent said “moderately successful.” Twelve percent said “not successful.”
Seventy-five percent said they experienced side effects including constipation (65 percent), sleepiness (37 percent), cognitive issues (32 percent) and dependence (29 percent).
Respondents also had concerns about the stigma associated with taking opioids. Forty-one percent said they felt judged by using opioids. While 68 percent of the patients had also been treated with antidepressants, only 19 percent felt a stigma from using those.
A major pharmaceutical company recently agreed to disclose in its promotional material that narcotic painkillers carry serious risk of addiction and not to promote opioids for unapproved, “off-label” uses such as long-term back pain. Researchers also note a lack of solid studies on the effectiveness of opioids in treating back pain beyond 12 weeks.
Patients with chronic low back pain, persistent pain lasting more than three months, should see a pain medicine specialist who uses an approach that combines a variety of treatments that may be more beneficial, said Dr. Buvanendran. These treatments include physical therapy, bracing, interventional procedures such as nerve blocks, nerve ablation techniques or implantable devices, other medications such as anti-inflammatories and alternative therapies such as biofeedback and massage, he said.
American Society of Anesthesiologists (ASA). “Many back pain patients get limited relief from opioids and worry about taking them, survey shows.” ScienceDaily. ScienceDaily, 23 October 2016.
Okay. So you’ve decided to embark on a fitness regime in order to shed some kilo’s, get fit or just for fun. New gym membership. Check. New sparkling runners. Check. Gym gear (a bit tight at the moment). Check. Alright, let me at that treadmill/rower/crosstrainer/zumba class!
“Hold on a second – what about your warm-up!”
“Warm-up” you scoff, “you’ve got to be kidding. No time to waste on that”.
Sorry folks, but the warm-up is an important part of your exercise routine and plays a crucial role in preparing your body for exercise. Skimp on the warm-up and you run the risk of injury during exercise or sport, as well as reduced performance levels.
“But what’s so important about doing a few stretches?” I hear you ask.
A proper warm-up involves more than just standing around stretching and talking. It prepares your body for the exercise/sport it is about to undertake and should simulate the actions involved.
The benefits of a warm-up are:
1) Increase in core body temperature
2) Preparation of muscles, tendons and joints for the stresses/strains of activity
3) Increase in nerve impulse conduction to muscles
4) Increase in blood flow to muscles
5) Increase in respiratory (breathing) rate
Let’s have a closer look at each of these benefits.
1. Increased core body temperature – this is important as it prepares the body for the change in activity level from being sedentary to exercising and gets the body into a ‘ready’ state. This also results in an increase in muscle temperature which makes them more pliable, supple and loose.
2. Prepares muscles, tendons and joints for activity – each sporting activity stresses the body in different ways so it is vital to prepare in a way that simulates these activities. For example, if you are a basketballer you need to include in your warm-up the jumping, running and change of direction that occurs during the game. If you pump weights at the gym, it is vital to perform a warm-up set of each exercise at a lower weight to allow your body to adjust to each specific movement.
3. Increased nerve conduction – muscles that are in a ready or aroused state react quicker and more efficiently than muscles that aren’t prepared for activity.
4. Increased blood flow to muscles – through increased blood flow there is an increase in oxygen flow to muscles as well as nutrient flow. This increased flow allows for improved performance
5. Increased respiratory rate – prepares the lungs for an increase in activity level and improves oxygenation of the blood flowing to the muscles.
Okay, so now that we know why we are performing a warm-up, what should it involve?
One common misconception out there these days is the importance of stretching as part of a warm-up. Note I said part of a warm-up.
Stretching on its own does not constitute a warm-up – rather it forms a critical part of one.
An effective warm-up has a number of very important key elements, which work together to minimize the likelihood of sports injury and prepare the individual for physical activity.
These key elements are:
1) The general warm-up
2) Static stretching
3) Sport specific warm-up
4) Dynamic stretching
1. The general warm-up
This consists of light physical activity such as walking, jogging, easy swimming, stationary bike, skipping or easy aerobics. The intensity and duration of the general warm-up is dictated by the fitness level of the participating athlete. For the average person, this part of the warm-up should last between 5 and 10 minutes and result in a light sweat.
2. Static stretching
Yes! Static stretching. This is a very safe and effective form of basic stretching. There is a limited threat of injury and is beneficial for overall flexibility. All the major muscle groups should be included for a period of 5 to 10 minutes.
Debate has raged about whether static stretching should be part of a warm-up and some studies have shown that static stretching can have an adverse effect on muscle contraction speed and therefore performance. It is for this reason that static stretching is performed early in the warm-up and always followed by sports specific drills and dynamic stretching. It is important these first two elements are completed properly as it allows the more vigorous and specific activities of elements three and four to then be performed.
3. Sport specific warm-up
In this part, you are specifically preparing the body for the demands of your particular sport or activity. During this part of the warm-up, more vigorous activities should be employed. Activities should reflect the type of movements and actions which will be required during the activity.
4. Dynamic stretching
Finally the warm-up should finish with a series of dynamic stretches. Caution should be taken with this form of stretching as it involves controlled, soft bouncing or swinging motions to take a particular body part past it’s normal range of motion. The force or the bounce of the swing is gradually increased but should never become radical or uncontrolled. These exercises should also be specific to the sport or activity.
Another important factor to keep in mind when undertaking any new exercise regime, is the time it takes for the body to adapt to training. If you have had a period of time away from sport or activity, then your body won’t be used to the stresses and strains put on it from exercise. It can take up to 4 to 6 weeks for your muscles, tendons and joints to become adjusted to the movements involved in your sport or activity.
During this period it is advisable to start with low to moderate intensity exercise which gradually builds over time. Heading straight up the red or blue arrow as your first exercise session in 3 or 4 months isn’t a great idea. Starting out with flat walks or jogging and gradually increasing time and intensity is a better way to start. After 4 to 6 weeks you will be at the stage where you can tackle more intense sessions.
The same goes for weight training. Starting with lighter weights and more repetitions will allow your tendons and joints in particular, to adapt to lifting load. Going too heavy too soon can lead to tendon injuries or severe muscle and joint soreness.
There is a common belief that there is not much you can do for osteoarthritis because the joint damage has already occurred and can’t be reversed. However it is often the inflammation of the tissue surrounding the joint and instability from the weakened tissues that lead to pain from an arthritic joint.
Our physiotherapists may be able to help you decrease the inflammation and pain around the joint and get you moving again. Here is some information about osteoarthritis and how we can help.
What is osteoarthritis?
Arthritis is a name for a group of conditions that cause damage to the joints in our body, usually causing pain and stiffness
Osteoarthritis is one of these conditions and it affects the whole joint, including bone, cartilage, ligaments and muscles
It is most prevalent in the joints of the hips, knees, neck, lower back, fingers and big toe, but can occur in any joint
It is degeneration of the joint structures, namely the cartilage (protective cushioning on the bony surfaces) and its underlying bone surfaces
Bony growths or spurs commonly known as osteophytes are common in osteoarthritis
Ligaments and muscles around the joint also deteriorate in osteoarthritis
It normally affects a joint on one side of the body i.e. it doesn’t normally occur bilaterally like other arthritic conditions
There are other arthritic conditions you may have heard of such as rheumatoid arthritis, juvenile arthritis, and ankylosing spondylitis.
Signs and symptoms
Swelling of the joints
Symptoms usually develop and worsen gradually over months or years
Affecting ability to carry out normal daily activities
Clicking/grinding in the joint
Loss of flexibility in a joint
What causes osteoarthritis?
Previous joint trauma/injury
Being overweight greatly increases your risk
High joint stress/repetitive use/heavy loads
There is an increase risk as you age and there is more ‘wear and tear’ on the joints
Arthritis can be diagnosed by taking a thorough history and physical examination
X-ray can help confirm a diagnosis – you may need to see your doctor to get a referral
Our physiotherapists can help you with:
Strength and exercise programme
Joint mobilisation/soft tissue techniques
Aids or braces
Weight loss programme
Medication and joint supplements – your doctor can guide you on the best options
Surgical options such as joint replacement
Pre-operative rehabilitation has been shown to improve outcomes post-operatively, so if you are requiring surgery come and find out how you can help speed up your recovery with pre-hab
Some hints for the colder months
Cold weather can exacerbate joint pain and joint stiffness. Remembering a few common sense tips can help people with osteoarthritis survive cold weather:
Dress warmly and layer up
Exercise indoors to stay motivated and warmer
Use a heated pool for exercise – talk to your physiotherapist for local options and classes
Ensure your vitamin D levels are adequate
You don’t have to wait for the warmer months to reduce pain associated with osteoarthritis! Book an appointment with a physiotherapist online 24/7,