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6 THINGS TO KNOW ABOUT BACK PAIN

3/6/2016

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In recent times, scientific research in the area of back pain has progressed. It challenges widespread notions so many of us hold about an ailment that seems to plague so many people all over the world.

1. BACK PAIN IS COMMON AND NORMAL

According to various epidemiological studies from around the world, anywhere from 60%-80% of people will experience back pain at least once in their lifetime. 1  As someone explained quite well, experiencing back pain “is like getting tired or becoming sad - we don't necessarily like it” 2, but it occurs to almost everybody at some point. What is not normal about these common occurrences of back pain is when someone doesn’t recover. 


2. SCANS ARE RARELY NEEDED AND MAY ACTUALLY LEAD TO MORE PROBLEMS

Conventional medical wisdom used to dictate that taking a good picture of the spine would help us solve back pain. However, good science shows us that this is most often not true.

A systematic review of scientific research projects about this issue done in 2014 3 found that what we think of as possible causes for people’s back pain – degenerated discs, arthritic changes, bulging discs, herniated discs – are actually found in large percentages of people with NO pain. 

For example, 37% of 20-yr old people showed disc degeneration on their scans. As age increased (decade by decade), the number of people with disc degeneration increased as well. At age 80, about 96% of people showed disc degeneration. Another 30% of 20-yr old people showed at least one bulging disc. That percentage increased to 97% by the age of 80. Facet degeneration (arthritic changes in the spinal joints between vertebrae) was found in 4% of 20-yr old people, 50% in 60-yr old people and 84% in 80-yr old people. Now, remember, NONE of the people in these studies that formed part of the review had ANY back pain!

What is more, we actually have good scientific evidence that shows that when we have our backs (and necks) pictured, and then hear from a well-meaning healthcare provider that our back is “damaged”, this can backfire. Fear, anxiety and avoidance of activity actually increased in many cases. 

In reality, many of the things that show up on scans are more like “wrinkles on the inside” - an indication of getting older that does not have to be painful.


3. MOVEMENT AND EXERCISE ARE GOOD AND SAFE

Many people with pain are afraid of movement and exercise when they hurt. They tend to avoid it because they think it may cause them to get worse. Unfortunately, not moving is the thing that actually causes more problems. The saying “motion is lotion” is true. Movement is like squirting oil into the joints. It improves circulation which brings nutrients to the area to get the healing process moving. It also can move the swelling out of the area. 

Here’s the good news: pretty much any type of exercise is good for back pain. The latest guidelines indicate that a combination of aerobic (walking, swimming, for example) combined with some strengthening and stretching works very well. 

When you are in pain, starting an exercise program can sometimes be difficult or scary. How can you be sure you won’t do too much and then experience more pain? Check out the helpful tip in one a previous posts (http://www.vtsphysicaltherapy.com/blog/breaking-bad).  


4. STRESS, POOR SLEEP, LOW MOOD AND WORRIES SHAPE BACK PAIN

How we feel emotionally can influence our experience of back pain (or any pain, for that matter). 

Stress, mood and anxiety levels, poor sleep patterns are all factors that are not only linked to health conditions such as cold sores, irritable bowel syndrome and tiredness, for example, but they also strongly affect back pain. Not surprisingly then, it is important to find ways that allow us to relax. 

5. MORE BACK PAIN DOES NOT MEAN MORE DAMAGE

Different people with the same injury can experience different amounts of pain. As mentioned above, different factors can affect how much pain we feel. Have you ever had the experience of looking down at your arm or hand, for example, and wondered when and where you got that scratch that is bleeding? Or witnessed the child who fell down but was fine until his over-reactive mommy jumped up and flew to the rescue only to cause the child to start crying well after the fact of the supposed “injury”? 

Our nervous system has the ability to control how much pain we feel at any given time. If a person has back pain, his/her nervous system may sometimes become hypersensitive, causing the person to experience pain, even though the initial injury (a strain, sprain, etc.) has healed. This can mean the person feels more pain when they move or try to do something that does not cause any damage to the spine. 


6. PERSISTENT BACK PAIN CAN GET BETTER

It is not uncommon for people to experience much frustration – even hopelessness at times – when they fail to achieve pain relief in spite of having undergone many different treatments. Generally this happens because most treatments only address one factor. Someone gets a muscle relaxer for the spasm in their back muscles, for example, but their sleep or posture patterns are not addressed. 

Pain can be significantly reduced and people can return to an overall healthier life when the different factors for each person are identified and addressed simultaneously. 

And this is precisely what physical therapists strive to do – to tackle back pain comprehensively. If you have lost hope that you will get better, it may be time to seek out a PT that will spend concentrated time with you looking at ALL the factors that may influence your experience with persistent back pain. 
​
If back pain is keeping you from doing and enjoying the things you like to do, you may want to give a PT a call.


References
1. Available at: http://www.who.int/medicines/areas/priority_medicines/Ch6_24LBP. Accessed October 26, 2015.
2. Available at: http://www.independent.ie/life/health-wellbeing/15-things-you-didnt-know-about-back-pain-31367264.html. Accessed October 26, 2015.
3. Brinjikji W, Luetmer PH, Comstock B, et al. Systematic literature review of imaging features of spinal degeneration in asymptomatic populations. AJNR Am J Neuroradiol. 2015;36(4):811-6. 


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Are We There Yet?

1/31/2016

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Recently, I received a brief private message from someone who wanted to find out more about my profession as far as post-operative care and rehabilitation are concerned. Facing orthopedic surgery can be quite daunting. What can we expect? How long will it take for the recovery?

Some of my previous patients have admitted to having had great reservations about starting rehabilitation after surgery. “Because,” they would say, “I have a relative (or friend) that had this done, and they told me PT is torture.” Or, “They said it hurt like h…!”

With these unpleasant news from well-meaning loved ones with less-than-perfect experiences and the uncertainties of a new and necessary event looming, it’s no wonder that our apprehension and anxiety levels tend to rise when we face procedures like total knee or hip replacements, rotator cuff repair or other shoulder surgeries, back surgeries, etc.


However, there’s really no need to hyperventilate or to indulge in extra doses of Xanax. Instead, let’s take some sage advice from the Spanish novelist Miguel de Cervantes Saavedra (of Don Quixote de la Mancha
fame), who said it right when he pronounced that “to be prepared is half the victory.”


First, take advantage of the fact that your surgeon really does want your experience to be a good one. Most surgeons will supply their patients with informational pamphlets, brochures, even videos explaining the selected procedure as well as some general path of recovery. If this information does not answer all your questions, ASK. 

Good surgeons know the research on patient need and satisfaction. Great surgeons are not only skilled with the scalpel; they also earn your trust by personally discussing with you questions and concerns you might have. 1 

Secondly, surgical pain management has come a long way in recent years. 2 You may want to ask the anesthesiologist and the nursing staff who will be taking care of you how they remain current with the latest guidelines for acute pain management. There is good evidence that uncontrolled acute pain results in various unwanted medical complications, including delay in wound healing. 2 Excellent research-supported guidelines exist that help the health care staff do a phenomenal job making your recovery as comfortable as possible. Look for providers who know and follow these guidelines.


​“What about pain with physical therapy and rehabilitation once I leave the hospital?” 

Again, we have learned a lot over the last decade or so about how pain works. The old adage “no pain, no gain” is actually rather antiquated when it comes to recuperating from surgery or injury. Rehabilitation after surgery may be uncomfortable, but it should not be painful, and most certainly never “hurt like h…”

To get the least painful post-operative rehabilitative care, you may want to look for a physical therapist that is trained in modern pain science. 3 

Lastly, how long will the recovery process take? There are many factors that influence recovery from orthopedic surgery or injury. Age, overall health and fitness before surgery, nutrition, and pain control, are some examples. However, outcome studies do help us make some general assertions of what a typical uncomplicated recovery looks like.  4, 5  

Rather than writing many words about studies like the ones I refe
renced above, here is an informative graph created by Rod Henderson, a practicing physical therapist in Texas. 6

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​As you can see, the majority of the recovery (60-75%) happens in the first 12 weeks. What is important to remember is that the rest takes longer. If we know this from the beginning, it may keep us from getting discouraged on our road to recovery. It may also keep us from developing unrealistic expectations, which could lead us to become impatient and engage in activities that we’re really not ready for, risking potential re-injury.


Research has shown that in many cases a good course of physical therapy can actually prevent the need for surgery. However, if you find yourself in a position where that is not the case, I hope you’ve learned a thing or two that will help prepare you more adequately for the procedure and for the road of recovery that lies ahead.
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References
1. Hoermann S, Doering S, Richter R, Walter MH, Schüssler G. [Patients' need for information before surgery]. Psychother Psychosom Med Psychol. 2001; 51(2):56-61.
2. Vadivelu N, Mitra S, Narayan D. Recent advances in postoperative pain management. Yale J Biol Med. 2010; 83(1):11-25.
3. Available at: http://www.bodyinmind.org/resources/journal-articles/full-text-articles/reconceptualising-pain-according-to-modern-pain-science/. Accessed January 28, 2016.
4. Kennedy DM, Stratford PW, Riddle DL, Hanna SE, Gollish JD. Assessing recovery and establishing prognosis following total knee arthroplasty. Phys Ther. 2008; 88(1):22-32.
5. Vissers MM, Bussmann JB, Verhaar JA, Arends LR, Furlan AD, Reijman M. Recovery of physical functioning after total hip arthroplasty: systematic review and meta-analysis of the literature. Phys Ther. 2011; 91(5):615-29.
6. Thanks to the gentlemen over at thestudentphysicaltherapist.com for making me aware of the existence of this graph. If you’d like to read up more about the graph, please see here (http://www.thestudentphysicaltherapist.com/home/explaining-rehab-time-frames)

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Breaking Bad

9/28/2015

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Virus
In the last post, I wrote about the effect that words can have on how much pain we actually experience and how much our level of movement can be affected by it. Not only can the word choices that healthcare professionals use affect our pain, but also the words we tell ourselves. Pain scientists have called these words or phrases “thought viruses”. They are conversations we’re having with ourselves that actually “keep the pain state going” even though the tissues have healed. Some examples of these thought viruses are:

“This has been going on for so long, I’ll never get better.”

“The x-ray (or MRI or CT scan, etc.) didn’t show anything; this must be really rare and bad.”

“I’m afraid I’ll hurt more so I’ll just sit very still here on the couch.”

“I’m fragile, maybe even broken.”


Here are a few things you can do to start to break free of a persistent pain state:  

1. Pay it some Mind:  We’ve already talked about our most powerful ally in our fight against pain – the brain. Use it! When you catch yourself caressing your favorite thought virus, remind yourself to stop. Snap your fingers; clap your hands, switch your watch to the other wrist, etc., as a way to physically reinforce the mental change you want to accomplish. Then replace those negative phrases with more helpful alternatives, like:

“This may have gone on for a long time, but I will continue to be an active participant in finding a solution.”

“The fact that the MRI doesn’t show any major issues is really good. My joints and soft tissues are okay.”

“I feel weak and fragile, but there’s plenty of good, solid research that shows that a regular exercise routine can change that.”


2. Get moving: Over and over research proves that movement is imperative for the body to function properly. If you’ve been in pain for a very long time and, consequently, have been quite sedentary, consider a gradual return to regular physical activity. Gradual or graded is the operative word here. Care needs to be taken that one doesn’t do too much too soon. An example of graded activity may be the following: Set a timer for 2 minutes and take a walk outside or ride a stationary bike until the timer rings. That’s all you need to do. The next day set the timer for 3 minutes and do your physical activity until the timer rings. Then, increase it to 5 minutes, and so on, gradually building up to 20 or 30 minutes.

3. Vary the input: Sometimes it helps to give the nervous system a new set of inputs. Through gentle manual therapy, it is possible to coax the system into lowering its guard against movement and speed up the tolerance to physical activity. So, seek out a healthcare professional, who specializes in manual therapy and jump-start your journey back to a more active and less painful life.


Image courtesy of Salvatore Vuono at FreeDigitalPhotos.net

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The effect of words on pain experience and movement

9/22/2015

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Thanks to advances made in the field of magnetic resonance imaging (MRI), it is now possible to visualize brain activity as it actually takes place. This type of imaging detects changes in the level of oxygen and blood flow during neural activity. When an area in the brain is active, it needs more oxygen, which means blood flow to that area increases. On the scan, these areas will appear to “light up”. With the advent of the functional MRI (fMRI) it has become possible to investigate and map which areas in our brains are responsible for the different neural processes required to keep us moving, thinking and feeling. Researchers interested in studying pain have, of course, also availed themselves of this technology.

One important discovery in the last few years has been the connection between what we think and feel about pain with the actual experience of pain. Turns out that how a physical problem is explained to us – that is, the choice of words that are used – can actually increase or decrease how much pain we perceive. Our willingness or fear to move seems to be directly related to this perception.   

The following single case study* using fMRI demonstrates the effect a session of therapeutic neuroscience education (TNE) had on a patient who was scheduled to have surgery for a lumbar disc herniation. TNE seeks to increase the patient’s knowledge and understanding of pain and to reduce the fear associated with injury and movement. The intricate concepts about what pain is and how it works are explained with metaphors and pictures that the patients can easily understand.

The images below** are of the fMRI scan of a patient facing surgery for a herniated disc in the low back. Preoperatively, this person received a session of TNE. The top row of images show the patient at rest. The middle row shows the patient performing a painful spine movement prior to TNE. The bottom row of images show the patient performing the same movement after TNE.
 


Pain

Pain is the result (output) of an interpretation (neural processes) that the brain makes in response to threat messages it receives (input). This does not mean that pain is imagined. It is a real and very individualized neural event as the fMRI demonstrates. It is, however, influenced by various outside sources. The words that are used to explain the reason for pain are one of those sources.***

Footnotes:
* Preoperative Neuroscience Education: Single fMRI case, submitted for Publication Louw, Diener, Peoples and Puentedura, 2014
** Permission to use these images was obtained from Adriaan Louw, PhD, PT, CSMT
*** It should be noted that a single case study cannot prove cause and effect. Randomized controlled trials (RCT) with larger numbers of individuals included in the trial are the rigorous studies one seeks. At least one such study was published by the same authors last year: Louw A, Diener I, Landers MR, Puentedura EJ. Preoperative Pain Neuroscience Education for Lumbar Radiculopathy: A Multi-Center Randomized Controlled Trial With One-Year Follow-Up. Spine. May 28 2014.


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Did you know that September is National Pain Awareness Month?

9/2/2015

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As we talked about in the last post, learning about pain is an important part of fighting it. The more we know about what it is we’re trying to manage and/or get rid of, the more successful we will be.

Chronic pain affects more people in America than diabetes, cancer and heart disease combined. Based on the latest calculations, 100 million Americans are in pain daily. That is about 1 of every 3-4 people! This translates into an estimated annual cost of more than $630 billion spent on medical care and lost productivity. And what about the personal costs – loss of function and quality of life? *

In its 2011 report, the Institute of Medicine emphasized the need for better understanding, assessment and management of pain, with an eye on prevention of chronicity and on promotion of patient self-management of pain. The call went out to train not only healthcare providers more thoroughly in the complex biological and psychosocial aspects of pain, but also to educate the public at large, and especially the patients.*

We already established that good science supports getting the brain involved in this battle against pain. (See the previous post here: http://www.vtsphysicaltherapy.com/did-you-know-blog/your-brain-is-ready-to-fight-pain). Throughout this month, I will post information to help you feel more empowered in your pursuit of a life that is not hampered by it. 


So, let’s get started with this 5-minute video produced by some kindred spirits from Down Under.


What is one thing you can try this week to help you begin your journey toward a healthier you? I would love to read your comments below. Do you have any questions you would like to address to me privately? Click here (http://www.vtsphysicaltherapy.com/contact.html) to send a private message. 

* Available at: http://www.iom.edu/~/media/Files/Report Files/2011/Relieving-Pain-in-America-A-Blueprint-for-Transforming-Prevention-Care-Education-Research/Pain Research 2011 Report Brief.
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Your Brain Is Ready To Fight Pain

8/16/2015

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Did you know that you already possess one of the most powerful weapons that exist to fight pain – any pain? Yes, you do! Curious to find out?

Physical therapists, physicians, chiropractors, and other licensed professionals who deal with people who are in pain can help by telling you what to do when you’re in pain. They can treat you with medicines, modalities (for example, ultrasound or electrical stimulation), adjustments, massages, needles, and/or various exercises. Most likely, you will get beneficial results from these various approaches. But how would you like to make sure to get the most out of any kind of treatment for your painful condition?

Fire up that wonderful brain of yours and learn some pain physiology! Over the last decade or so, some really exciting research has emerged about the brain’s role as one of the major players in the experience of pain. Clinicians and researchers like Lorimer Moseley, David Butler, Adriaan Louw and others have demonstrated that when a person learns about the physiology of pain – how pain works in the body – and combines that learning with movement therapies, he or she has better outcomes as far as pain relief, physical capacity, and improved quality of life are concerned.

Knowledge indeed is power. So do yourself a favor: Seek out a health care provider who is trained in modern pain science and have her help you understand these physiological concepts. Your brain is ready and your body will thank you!

Here is what one of my patients, JH, had to say after he learned some of the modern pain science facts. “I greatly appreciated the fact that I was trusted with knowledge and not expected to return often to the expert who held the secret to my recovery. Everyone needs to understand their bodies better, no matter how much a person knows, there is still more to marvel at and work towards improving. If you're hurt, you need help, and this is a great place to find the help you need.”

Get into the driver’s seat and get your nagging (or new) pain issue under control. Contact me today and let’s get you going with a comprehensive plan of attack that applies modern pain science, gentle hands-on therapy, and some healthy movements.

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Direct Access to Physical Therapy Services in the State of Ohio

7/25/2015

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    Author

    Victoria T. Strickland, Doctor of Physical Therapy / Owner at VTS Physical Therapy

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