Posted on Wednesday, October 7, 2015

Chronic Pain: Is There Hope?

By Jerry Henderson on October 7, 2015.

It is clear that to me that there is a chronic pain epidemic in this country. My belief was confirmed by some disturbing results from a cross sectional survey of over 27,000 people on the prevalence of pain. The study was conducted by Johanne and associates in 2012[i] and it showed:

Approximately 30% of the respondents had long lasting chronic pain or recurrent pain, and:
- Most had either lower back pain (8%) or pain from other osteoarthritic conditions (4%).
- Half had daily pain.
- About 1/3 of those reported their pain as severe (at least 7 on a 0/10 verbal pain rating scale).
Prevalence increased with age, lower socioeconomic status, and unemployment.

An Institute of Medicine report estimates that 116 million Americans suffer from chronic pain and that the combined medical and financial cost due to lost productivity is $635 million per year,[ii] which is more than the annual costs of cancer, heart disease, and diabetes.

Describing Chronic Pain

There are many definitions of chronic pain, but one of the most widely accepted is any pain lasting longer than 12 weeks. Experiencing pain for longer than 12 weeks is simply not normal. In contrast, acute pain, that is, pain lasting for a shorter period of time, is our internal warning system about serious tissue damage.

Think about the difference between the qualities of the pain you experience from a minor skin cut compared to the pain you have probably experienced at some time in your life from your lower back.

The pain from a skin cut feels sharp. You can tell, without looking where the cut is on your skin, and you can estimate whether or not the cut is serious. The lower back pain may initially feel like a sharp, stabbing pain, but after a few days it often develops into a deep aching. You don’t have a good idea of how badly you are hurt, and you have a hard time describing where it hurts. In fact, the location of the pain may change over time.

As the skin cut heals, the pain resolves quickly. As the low back heals, the pain may resolve quickly, but (for reasons that are not well understood) it may not. That deep, aching pain may just continue for weeks, and it may cause complex changes in your brain chemistry that make it even worse. Over time, this type of pain builds on itself to the point that in the worst cases it becomes completely disabling and is often associated with clinical depression.

I often told my patients that pain of this sort is a liar. It may provide important clues about the source of the problem, but that’s all–just some clues. Other than clues, we shouldn’t rely too much on this type of pain to tell us much of anything.

“If I Had a Hammer….”

The old saying, “If you have a hammer, everything looks like a nail,” holds true for chronic pain treatment. The physician tool chest (which includes narcotic medications, injections, surgery, and imaging studies) seems to be woefully inadequate at treating this type of pain.

Use of narcotic medications works great for acute pain, but they are dangerously addicting and have other perverse side effects like making clinical depression associated with chronic pain even worse in some cases. In my experience, the term “Pain Clinics” is often code for drug rehabilitation for patients who have been addicted to narcotic pain medications for their chronic pain.

The dismal record of surgery, particularly spinal fusion, for low back pain is well documented. The New York Times reported on a recent study from the Journal of the American Medical Association indicating that injections for non-specific lower back pain are ineffective, even though they are done routinely[iii].

What is the Answer?

Chronic pain is pervasive, disabling, and costly. It causes untold suffering. It can rob patients of their livelihoods. Typical care for chronic pain isn’t very effective. I believe that physical therapy is the best treatment available.

I find this excerpt from an article published by the National Institutes of Health very telling:[iv]

Self-management of chronic pain holds great promise as a treatment approach. In self-management programs, the individual patient becomes an active participant in his or her pain treatment—engaging in problem-solving, pacing, decision-making, and taking actions to manage their pain. Although self-management programs can differ, they have some common features. Their approach is that the person living with pain needs help learning to think, feel, and do better, despite the persistence of pain. Improving communication with the healthcare provider is part of that empowerment.

Through NIH-supported research, starting successful self-management programs has reduced many barriers to effective pain management, regardless of the underlying conditions. Individuals who participate in these programs have significantly increased their ability to cope with pain. They improve their ability to be active, healthy, and involved members of their communities. In fact, new research suggests that the best self-management programs teach people different ways of thinking about and responding to pain, making their actions to relieve it more effective.

Read that excerpt carefully. Doesn’t that sound like physical therapy?

Physical therapists need to take the lead on being the providers of choice for these types of problems. No one can do it better.

[i] http://www.ncbi.nlm.nih.gov/pubmed/20797916

[ii] http://www.amednews.com/article/20110708/profession/307089996/8/

[iii] http://well.blogs.nytimes.com/2013/07/18/looking-for-alternatives-for-back-pain-relief/

[iv] https://www.nlm.nih.gov/medlineplus/magazine/issues/spring11/articles/spring11pg5-6.html

About Jerry Henderson

Jerry Henderson has been a physical therapist for over 25 years and is passionate about providing his PT colleagues with proven processes and state of the art systems to enable them to excel in delivering excellent patient care. He currently serves as VP for Clinical Community at Clinicient, Inc. http://www.clinicient.com/

Posted on Wednesday, August 12, 2015

Q & A: Do I Need an MRI for Low Back Pain?

Q. I have been dealing with low back pain on and off for the past several months. The pain is severe. I cannot participate in my normal exercise activities. In fact, I struggle just getting in or out of my car. My doctor says my X-ray results are fine, but do I need an MRI? -Brad

A. Thanks, Brad, for the question! I am often asked if an MRI is necessary when someone is experiencing low back pain (LBP). You state that your X-ray results are fine, so that immediately rules out the possibility of certain types of injuries such as a fracture or more chronic conditions like spinal stenosis. Fortunately, most LBP is mechanical–meaning it is from a physical or structural cause and isn’t related to conditions such as fractures, cancer or infections.

The answer to your question is no. An MRI is not needed in a majority of cases of LBP. It is best to diagnosis the cause and the best treatment strategy through a thorough physical assessment because most LBP is mechanical. There is definitely a time and place for an MRI. There are very clear indications when additional follow up such an MRI is necessary. Your physician will take a thorough history and determine if it’s necessary based on your history and examination. (To learn more about the different types of imaging, including an X-ray, CT Scan, and MRI, please refer to Q & A: Which Type of Imaging to Use?)

To safely self-treat your low back pain, first take a moment to assess your symptoms and pain level. What led to your pain and/or injury? Did the pain come on suddenly or slowly? Evaluate the severity of the injury. If you’re experiencing any of the following, please seek immediate medical attention:

Loss of bowel/bladder function.
Uncontrollable pain. The pain is so severe you cannot function or move.
You are losing muscle function or control. The muscles in the legs will no longer work. (This is different than pain preventing the muscle from working.) This sensation of paralysis occurs when the muscles will not actually function.
Significant loss of sensation in the leg or groin area. This is not a tingling sensation, but an actual loss of sensation. For example, you cannot feel the toilet paper when you wipe after using the toilet.
Numbness, pins and needles or severe pain in the toes or lower leg.
Any history of cancer or tumor. The pain did not have a specific and correlated mechanism for injury.
Onset of pain without any known mechanism for the injury. (Thoroughly consider your activity. Many times, a slow onset of pain begins several hours after performing an activity.)
A high fever or any other symptoms in relation to your low back pain or you generally start to not feel well.

Most LBP will have a directional preference for extension. A majority of injuries occur when performing a forward biased (flexed movement) like chronic slouching or a spinal flexion biased movement. I will discuss an extension biased program because it is by far the most common directional preference. Flexion biased programs are often found in older adults particularly in cases of spinal stenosis.

In the case of mechanical LBP, you should be able to alter and change your LBP within a short period of time. First, establish a directional preference by identifying a pattern to the pain. Does the pain get worse when you bend over or does it improve? What happens when you repeat this movement? Determine how your pain responds. If it spreads away from the spine and down into the leg, beware that you are moving in the wrong direction. Stop that particular movement, and instead try moving in the opposite direction. If you were moving into flexion, try extension. If you had trialed extension biased movements, try flexion.

The rule of thumb for movement: If the pain worsens by spreading peripherally down the buttock and into the leg and/or foot, then the condition is worsening. We must stop that activity. If the pain centralizes and returns back toward the spine (even if the pain worsens slightly), then keep moving as the condition is actually improving. For a thorough discussion and an excellent treatment resource, please refer to Treat Your Own Back by Robin A. McKenzie.

In my experience, most episodes of LBP tend to respond better to extension biased movements. If flexion or extension doesn’t help or change the pain in any way, then you may need assistance from a medical provider. I highly suggest seeking a qualified and competent physical therapist who works with clients suffering from LBP. The American Physical Therapy Association offers a wonderful resource to help find a physical therapist in your area. In most states, you can seek physical therapy advice without a medical doctor’s referral (although it may be a good idea to seek your physician’s opinion as well).

Thanks again for the question, Brad, and good luck with resolving your pain! For more self-treatment strategies for low back pain, including specific exercises and recommendations, please refer to the following posts: How to Safely Treat Low Back Pain, 12 Sure Fire Ways to Injure Your Back, and My Top 7 Tips to Prevent Low Back Pain While Traveling.

Don’t let LBP affect your ability to stay active and keep enjoying your favorite activities! Learn how to prevent, self-treat, and manage LBP so you can get back to your daily life and exercise goals more quickly without additional unnecessary and costly medical bills!

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In my book, Treating Low Back Pain during Exercise and Athletics, you will learn how to address specific causes of LBP as well as the best practices on how to prevent and self-treat when you experience an episode of LBP. In this step-by-step LBP rehabilitation guide (complete with photos and detailed exercise descriptions), you will discover how to implement prevention and rehabilitation strategies to eliminate pain and get back to training and exercise sooner.

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Posted on Monday, October 20, 2014

How to Safely Self-Treat Low Back Pain

Did you know that an estimated $50 billion dollars is spent annually on back pain related issues? Low back pain (LBP) is one of the most prevalent medical conditions treated in the United States and throughout the western world. It affects nearly 80% of the U.S. population at one time or another. It’s one of the top reasons for physician visits and one of the most common reasons for missed work days. The previous post, 12 Sure Fire Ways to Injure Your Back, addressed potential risk factors for low back pain. This follow-up post includes how to safely self-treat your low back pain and helpful methods for a speedy recovery. (Not to mention, possibly saving you time and money by avoiding a physician visit for minor pain!)

Loss of bowel/bladder function.
Uncontrollable pain. The pain is so severe you cannot function or move.
You are losing muscle function or control. The muscles in the legs will no longer work. (This is different than pain preventing the muscle from working.) This sensation of paralysis occurs when the muscles will not actually function.
Significant loss of sensation in the leg or groin area. This is not a tingling sensation, but an actual loss of sensation. For example, you cannot feel the toilet paper when you wipe after using the toilet.
Onset of pain without any known mechanism for the injury. (Thoroughly consider your activity. Many times, a slow onset of pain begins several hours after performing an activity.)

Fortunately, most LBP is mechanical–meaning it is from a physical or structural cause and isn’t related to conditions such as cancer or infections. Most LBP will have a directional preference for extension. A majority of injuries occur when performing a forward biased (flexed movement) like chronic slouching or a spinal flexion biased movement. For discussion purposes, I will be addressing an extension biased program.

You should be able to alter and change your LBP within a short period of time. First, establish a directional preference by identifying a pattern to the pain. Does the pain get worse when you bend over or does it improve? What happens when you repeat this movement? Determine how your pain responds. If it spreads away from the spine and down into the leg, beware that you are moving in the wrong direction. Stop that particular movement, and instead try flexion biased movements. In my experience, most episodes of LBP tend to respond better to extension biased movements. If flexion or extension doesn’t help or change the pain in any way, then you may need assistance from a medical provider.

The rule of thumb for movement: If the pain worsens by spreading peripherally down the buttock and into the leg and/or foot, then the condition is worsening. We must stop that activity. If the pain centralizes and returns back toward the spine (even if the pain worsens slightly), then keep moving as the condition is actually improving. For a thorough discussion and an excellent treatment resource, please refer to Treat Your Own Back by Robin A. McKenzie.

Although most LBP isn’t considered serious, the pain tends to re-occur. One major reason for this is that the deep stabilizing muscles known as the multifidus muscles reflexively shrink, weaken, and lose function. Without proper rehabilitation, the muscles will not fully recover. This increases the risk of future episodes because the spine no longer has the ability to stabilize itself normally.

How to Safely Self-Treat Low Back Pain:

Perform Press-ups – Once you have injured your back, immediately start press-ups. Perform this exercise with high repetitions and frequently throughout the day as long as the pain does not periperalize down the buttock and into the leg and/or foot. Lie on your stomach and perform 10-20 press-ups. Move slow and easy, but work your way up to full motion multiple times a day.

Perform Standing Back Extensions – After sitting, stand up and perform standing back extensions. Ideally, perform this exercise at least 10 repetitions each time you stand.

Activate the Multifidus – Start exercises to activate the multifidus muscles as soon as possible. Think spine extensor muscle activation. Again, perform this exercise frequently during the day after the initial injury. The Lumbar Extensor Exercises are designed to progressively activate the multifidus muscles (with the final exercise being the most challenging). Once the pain subsides and muscle function improves, more advanced lumbar extension strengthening and stabilizing exercises should be performed to decrease your risk of re-current low back pain.
Don’t Sit – Walking is critical to your recovery! It’s the number one way your spine receives nutrients and disposes of metabolic waste products. Walk frequently, and try to avoid any prolonged sitting.
If you Sit, Use Good Posture – Use a McKenzie Lumbar Roll to help insure a good lumbar curve. If you can’t sit comfortably, listen to your body and don’t sit! Be sure to stand up and walk every 20-30 minutes. Make sure you stand with good posture as well.
Stretch the Muscles of the Legs and Pelvis – Hamstring, Hip Flexor, and Piriformis Stretches for LBP help to reduce muscle spasms and tightness throughout pelvis area when performed daily. Stretch for at least 30 seconds at a time, 2-3 times each session.
Reduce Inflammation and Support the Healing Response – I recommend starting a thirty day course of CapraFlex by Mt. Capra. CapraFlex is an organic glucosamine and chondroitin supplement which also includes an herbal and spice formulation designed to naturally decrease inflammation and support healing. I recommend it to anyone recovering from an injury or attempting to prevent injury when performing at a very high level. I personally use it, and in my practice, it has helped clients recover faster and prevent injury. It can interfere with some blood thinning medication, so if you are on this type of medication, please check with your physician.
Ice as Needed for Pain – The rule for icing is to apply ice no more than twenty minutes per hour. Do not place the ice directly against the skin, especially if you are using a gel pack style. Individuals with poor circulation or impaired sensation should take particular care when icing.
Use Topical Analgesics for Pain – There are many topical agents which can be used for pain. My two favorites to help manage pain and stiffness are Arnica Montana (an herbal rub) and Biofreeze.
Be as Active as You Can – Don’t stop moving! It’s important that you remain as active as you can. You should taper certain activities that you know will increase your pain. This typically would be activities involving heavy loading of the spine such as squats with weight, deadlifts, and other activities that may cause forward flexion (particularly under a load). As you are able to, continue to work on cardiovascular conditioning and core muscle activation, particularly the lumbar extension exercises. Remember the concept of peripheralization and centralization. If your pain progresses from the area of the injury into your leg, then you need to stop that activity. If the pain remains constant or is progressing out of the leg, then continue with the activity as you are helping the body to heal.
Ask for Help – Yes, even physical therapists have to ask for help sometimes! Many useful manual techniques can help to manage LBP. You just can’t perform them on yourself. If your pain is not improving, I highly suggest seeking a qualified and competent physical therapist who works with clients suffering from LBP. The American Physical Therapy Association offers a wonderful resource to help find a physical therapist in your area. In most states, you can seek physical therapy advice without a medical doctor’s referral (although it may be a good idea to seek your physician’s opinion as well).

Low back pain is a serious and debilitating condition. It will either most certainly affect you or someone close to you. Be pro-active in maintaining a healthy back by incorporating these helpful methods for a speedy recovery. Don’t let LBP affect your ability to stay active and keep enjoying your favorite activities!

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Learn how to prevent, self-treat, and manage LBP so you can get back to your daily life and exercise goals more quickly without additional unnecessary and costly medical bills!

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Posted on Monday, October 13, 2014

12 Sure Fire Ways to Injure Your Back

You caught me red-handed! A physical therapist with a lapse in judgment which lead to an injury that I could have avoided had I followed my own advice. During an early morning workout, I recently tweaked my low back. I’m guilty of being exhausted, using poor technique, and not taking a rest day. Sound familiar?

In the following days (as I was forced to rest although I would rather have been at the gym), I drafted a rather cheeky list of risk factors and how to maintain a healthy back.

12 Sure Fire Ways to Injure Your Back:

Start Smoking – Smoking is a major risk factor for low back pain (LBP). The chemicals in cigarette smoke affect both the lunges’ ability to exchange oxygen and the body’s normal healing response. These chemicals alter the blood supply to the discs and other spinal structures which affects nutrient exchange and increases the risk of pain. Healing time for all medical conditions worsen with smoking.
Be Male – Males have a higher risk of LBP. Females tend to experience more cervical or neck pain. (Obviously, you have very little control over this factor other than the knowledge that you’re at an increased risk if you are a male.)
Choose Parents Who have Experienced LBP – A family history of low back pain increases your risk. In some cases, this may be due to actual structural deformities which may be genetically linked. More commonly, it’s a learned behavior, such as chronic sitting and slouching (poor posture), that can lead to a higher risk of LBP.
Prior Episodes of LBP – Once you have experienced LBP, you are more likely to have re-current episodes. This is partially due to weakness in the deep multifidus muscles that help support the spine and prevent shearing forces. This weakness can be addressed with proper physical therapy intervention.
Have a Baby – Pregnancy increases your risk for LBP due to structural changes as the baby develops and hormones change. The expectant mother releases relaxin, a hormone which loosens the whole body, to prepare for the baby’s delivery. Again, a risk worth taking! Most women can manage the pain by modifying posture and movements while learning techniques for self-management.
Don’t Exercise – A sedentary lifestyle will increase your risk for LBP. The spine is designed to work and move. In order for the spine to remain healthy, it requires exercise and movement.
Sit for more than 2 Hours a Day – Sitting for a long period of time not only affects your general health status in a negative way, but it also increases your risk for LBP. To increase your risk further, be a heavy equipment operator who sits on a vibrating surface! Please refer to The #1 Way to Extend Your Life Span for the reasons why sitting has such a negative effect on your body.
Practice Poor Posture – In western culture, we spend most of our day sitting slouched or standing hunched over. This is an excellent way to increase your risk for LBP. It’s one of the major risk factors for disc herniation and development of spinal stenosis. Please refer to How to Improve Posture & Eliminate Pain for exercises that can help you to develop better posture and strength to eliminate back pain.
Don’t Warm Up Before Exercise – This is a common mistake which can lead to injury. Jump out of your bed in the morning without warming up, and then start your exercise routine. (Please don’t!) Instead, prepare your body for challenging activities in order to avoid injury. A warm up should consist of a cardiovascular component and a dynamic stretching routine of the actual exercises you will be performing to insure you’re ready for the movement. This is also pertinent for weightlifting and running.
Keep Moving even when Exhausted – This is a common problem among CrossFitters (including myself). Just keep pushing yourself even when you can’t see straight. Typically, this results in poor technique which further increases your risk. Combine poor technique with muscles which can no longer perform the proper movement pattern, and you are likely to become injured. High Intensity Training (HIT) is a wonderful form of exercise and has many health benefits as long as you’re able to properly perform the exercise.
Use Poor Technique – Poor technique, along with feeling exhausted, often occurs when performing exercises that are too advanced. Performing unfamiliar lifting techniques or lifting too much weight will likely result in poor technique. Please see your coach, athletic trainer, or physical therapist for the proper technique for your activity of choice.
Keep the Training Volume High – Who needs a rest day? All of us can benefit from taking a break. Training every day without regard to rest is an excellent way to cause over training syndrome and injury.

Low back pain is a serious and debilitating condition. It will either most certainly affect you or someone close to you. Be mindful of your risk factors and be pro-active in maintaining a healthy back! Don’t let LBP affect your ability to stay active and keep enjoying your favorite activities!

AVAILABLE NOW ON AMAZON!

Learn how to prevent, self-treat, and manage LBP so you can get back to your daily life and exercise goals more quickly without additional unnecessary and costly medical bills!

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Posted on Monday, June 30, 2014

My Top 7 Tips to Prevent Low Back Pain While Traveling

This time of year, many of us plan to hit the road (or the sky) to visit family and/or friends or to get away for some rest and relaxation! Now imagine crawling around on the floor because you can’t stand up as your best laid plans are derailed by a bad episode of low back pain (LBP). Why the pain while vacationing? Sitting is a major contributing factor to low back pain. Combine sitting followed by bending and twisting as you load and unload heavy bags—you’re setting yourself up for a miserable time!

Low back pain (LBP) is estimated to affect nearly 80% of the U.S. population at one time or another, and it is one of the top reasons for physician visits. Fortunately, most LBP is mechanical–meaning it is from a physical or structural cause not related to conditions such as cancer or infections. The problem with this type of LBP is that it usually comes back. People who have had an episode of mechanical LBP are 90% more likely to experience it again. It’s best to minimize your risk factors for experiencing LBP by being pro-active.

My Top 7 Tips to Prevent Low Back Pain While Traveling include:

If you smoke, stop. Smoking is one of the top risk factors in LBP. Even cutting back can decrease your risk.
Limit the amount of sitting that you spend at one time. Get out of a sitting position every hour, and ideally, walk. If you aren’t able to walk, then try to shift your position at least once every twenty minutes. Frequent position changes can help to avoid LBP.
Sit with good posture. Whenever possible, make sure your knees stay below your hip level and that you are able to maintain your natural lumbar curve. A great tool to help you with this is a lumbar roll.
Standing Back Extensions: After sitting, stand up, and perform standing back extensions. I encourage performing at least 10 repetitions each time you stand.

Stretch Your Hip Flexors: After performing standing back extensions, it’s time to stretch your hip flexors. The hip flexors tend to tighten up during prolonged sitting. When they spasm, it can cause LBP because they attach directly to the spine. Stand with a good upright posture, with your feet straight ahead, and bend your front knee until you feel the opposite hip flexor stretch. Hold for 30 seconds, and then repeat two to three times on each side.

Press-ups: Lie on your stomach and perform 10 to 20 press-ups before you leave from home, when convenient and safe during your travels, and when you arrive at your destination. Go slow and easy, but work your way up to full motion. I encourage performing this multiple times a day as time allows.

Stretch Your Hamstrings: Find a doorway and stretch your hamstrings before you leave from home, when convenient and safe during your travels, and when you arrive at your destination. I recommend at least one minute per side and preferably two repetitions per side.

My final tip to manage low back pain is to work with a physical therapist to learn methods to strengthen the lumbar extensor muscles and core musculature. If available, seek a physical therapist who utilizes the MedX system as it has solid research on LBP and targeted strengthening. Research clearly indicates that the right targeted exercises are the most effective way to manage LBP. If you are prone to LBP and want to dig deeper on self-treatment options, my rehabilitation guide can help you.

AVAILABLE NOW ON AMAZON!

Learn how to prevent, self-treat, and manage LBP so you can get back to your daily life and exercise goals more quickly without additional unnecessary and costly medical bills!

BUY NOW