Why you may not need to worry about disc herniations in my opinion …..

Working as a musculoskeletal physiotherapist I often see people walk into the clinic room with large envelopes in their hands housing their “latest” MRI or CT scans. I am always eager to look at these, I mean I am not ashamed to admit that I love anatomy and seeing the images is a tad exciting.

An interesting thing I’ve noticed though is that I often get shown imaging of previous disc injuries in the spine that can be up to 4 years old. I often wonder if people bring them in because they think they are still walking around with the same old disc pathology they once had 4 years ago.

When you think about it, it makes sense… I mean have you noticed that when a friend, colleague or family member has a back injury they often say “I’ve done my back in” and use terms like “I’ve got a slipped disc” or “I have a bulging disc”. These terms sound quite sinister in nature and if a disc has “slipped” or “bulged” out it seems impossible to think it can slip back in.

So what is a disc herniation? I often think of the discs in the spine like Chinese steam buns, firmer on the outside with a soft filing on the inside. In reality the filling on the inside is like the consistency of tooth paste. When there has been a disc herniation there is a displacement to the disc material which then at times causes changes to the nerve root or spinal canal (kjaer, 2016).

Kjaer (2016) studied 140 herniated discs over an 8 year period and found that herniated discs spontaneously resolve without treatment. As well as this they found that most of them were stable in nature and would not get any worse or better. If you are wondering how they just resolve on their own well keep wondering because there are some theories but no-one knows for certain.

As well as this a Meta-analysis by Zhong et al (2017) found that overall there is a high incidence of disk reabsorption to 66% of the patients who received conservative treatments which consisted of anything that was not surgery or injections.

Resolution of Lumbar Disk Herniation without Surgery
Hong, J.and Ball, P DOI: 10.1056/NEJMicm1511194

Now I don’t want to create a sense of triviality to disc injuries because they sure can be painful and alter your normal routine for a few weeks… but next time a friend, family, colleague or even yourself suffers from a disc injury perhaps you can remember this article and the recent statics that show a large amount of herniated discs spontaneously resolve and that your body is a self healing mechanism. I mean it is constantly trying to find it’s homeostasis, give it the right environment conducive to healing and you will be surprised how well it heals injuries.

References

  1. Zhong M, Liu JT, Jiang H, Mo W, Yu PF, Li XC, Xue RR. Incidence of Spontaneous Resorption of Lumbar Disc Herniation: A Meta-Analysis. Pain Physician. 2017;20(1):E45–E52. PubMed #28072796.
  2. Kjaer P, Tunset A, Boyle E, Jensen TS. Progression of lumbar disc herniations over an eight-year period in a group of adult Danes from the general population: a longitudinal MRI study using quantitative measures. BMC Musculoskelet Disord. 2016 Jan 15;17(1):26. PubMed #26767364

Stress and healing in my opinion ….

I think It’s safe to say that it’s common knowledge that stress disrupts life in many ways. It can effect sleep, thoughts, feelings, behaviour and even increase the risk of certain health issues. But what about when you have musculoskeletal symptoms, such as lower back pain, headaches or neck pain how do you think stress effects these issues and more importantly have you ever given a thought as to how stress can impact your healing process when you have an injury whether that be an inflamed joint, an unhappy disc, an ankle sprain?

The healing process is a complex one and I am sure we have all taken it for granted when we see a blister or a paper cut heal in a matter of days. But when you delve into what has happened for this healing to occur you realise there was a complicated range of vascular changes, cellular changes and neural changes. Have you ever had a wound in the past that has taken a slower amount of time to heal? What was your mental health like? Was there an increase in your general stress levels?

There is an array of literature out there that shows increased stress levels can lead to a significant decrease in tissue healing. Alford (2007) suggests that stress can delay healing up to 60%. What has been suggested is that there is a reduced amount of pro inflammatory cytokines at the site of injury of individuals who are stressed. These pro inflammatory cytokines play a major role in tissue repair by clearing the wound as well as bringing in cells that promote healing and repair.

March et al (1998) found that there was 40% slower healing time to students who were trying to heal a hard palate wound during exam block compared to another hard palate wound during the holiday break. It really makes you think that even every day stressors can have a major impact to healing. Jennings et al explain that exposure to acute or chronic stress can even increase pain levels in a clinical environment.

As a physiotherapist there are many approaches to help create an environment conducive to healing, from graded movement, education, hands on therapy but if stress alone can delay healing time and even exacerbate pain symptoms perhaps what we must not forget is finding ways of decreasing the stress response. 

Things that put me into a parasympathetic mode (i.e. the part of the nervous system associated with rest and digest) and help decrease stress include: Diaphragmatic breathing exercises, writing a list of things that I am grateful for, Zen Thai Shiatsu treatments, any sort of moving including walking, jogging, yoga, stretching, strength training,Daily self care that includes a handful of things I do every morning that helps me start my day in the best way possible.

What would be your way of decreasing stress in your life?

REFERENCES

Alford, L. (2007). Findings of interest from immunology and psychoneuroimamunology. Manual Therapy, 12(2), 176–180. doi:10.1016/j.math.2006.06.007 

Marucha, P. T., Kiecolt-Glaser, J. K., & Favagehi, M. (1998). Mucosal Wound Healing Is Impaired by Examination Stress. Psychosomatic Medicine, 60(3), 362–365. doi:10.1097/00006842-199805000-00025

Jennings, E. M., Okine, B. N., Roche, M., & Finn, D. P. (2014). Stress-induced hyperalgesia. Progress in Neurobiology, 121, 1–18. doi:10.1016/j.pneurobio.2014.06.003

Less is more in my opinion ….

I feel that often in life we over complicate things, sometimes to get to our rehabilitation destination we feel we need an expensive gym membership, the latest home gym equipment, we need to purchase weights, buy exercise toys or have the latest exercise clothing before we can even start our rehabilitation journey. But I think what we often fail to remember is that most of the time in life less is more.

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It seems that this is even true for lower back pain rehabilitation. Lower back pain is common in developed counties with a prevalence of 60-80% in one year¹. Think about your family members more than half of them would have experienced lower back pain in the space of one year!

Historically strengthening has been the approach taken to improve function with people suffering from lower back pain. However in 2012 Shnaydema & Katz-Programe showed that a 6 week walking program was just as effective as a strengthening exercise for lower back pain¹.

Walking-is-mans-best-medicine.-Hippocrates

For a long time aerobic exercise has been shown to decrease pain, depression, fear of movement and increase mood. Walking is known to be the safest form of aerobic exercise as it has the lowest rate of injury¹.

Shnaydema & Katz-Programe studied people who were suffering from chronic lower back pain between the ages of 18-65 years. They had 2 groups, the walking and the strengthening group. The walking group started off walking for 20 minutes and increased the time by 5 minutes every week eventually walking 40 minutes by 6 weeks. The exercise group performed strengthening exercise for the trunk and limbs. Both groups performed their form of exercise twice a week.

Now although the study didn’t have a long follow up period it is a great reminder that sometimes simplicity is key. I mean going for a walk twice a week for 20-40 minutes for little over a month seems achievable, don’t you think? I guess one could only imagine what 6 months of this could feel like.

Really at core of this is the fact that no matter type of movement you choose to do it is likely to have some positive changes in some way, I mean motion is lotion. It is just nice to know that simply doing some regular walking might just be all you need to do.

References:

  1. Shnayderman, I., & Katz-Leurer, M. (2012). An aerobic walking programme versus muscle strengthening programme for chronic low back pain: a randomized controlled trial. Clinical Rehabilitation, 27(3), 207–214. doi:10.1177/0269215512453353

Posture in my opinion …….

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Physiotherapists around the world have historically been nagging people to watch their posture for eons, probably with very little awareness of their own! I won’t lie I was trained to do the same and have done the same until I realised it really was a lost cause most of the time.

Not to say that those who I would ask to be more aware of their posture didn’t listen but rather it was really an unrealistic task for most. Sure most of us could be cued to move into the correct posture; shoulders diagonally down, long through the back of the neck, don’t lock your knees blah blah blah. But no one could sustain this for more than a few seconds.

Why?

There are many things that are required in order to have what is considered aesthetically “good posture”

  1. Mobility – your joints need to be able to move with ease other wise your muscles are likely to work against a significant amount of resistance from joint stiffness.
  2. Strength – if you really want to work on your posture …… move and move with some resistance, regularly!
  3. Endurance – really your muscles don’t just need to be strong but they also need to have the endurance to maintain a position for an extended period of time.

These are all things that are achievable but take time, commitment and consistency so by simply just asking you to watch your posture for the sake of better posture is a delusion.

Now don’t get me wrong I often have times in my day where I am standing in line at the supermarket where I practice my ‘good posture’ position, however I use this as a posture reversal exercise. When I do this I am unloading structures and giving some respite to others for a few minutes in my day.

I think there are 2 important things to note:

  • There really is no such thing as a “bad posture”. There are many tasks in life that require you to adopt different body positions. Your body was made to move in a variety of ways and it is not necessarily the position that is the problem, the issue really is around sustaining any posture for an excessive amount of time, our bodies don’t like any static posture (no matter what it looks like) and this is where you can run into some problems.

“Your Best posture is your next one” Adam Meakins (The sports physio)

  • The posture is only an issue if it causing you symptoms. There is a significant amount of variance with human morphology so not everyone will fit into the “neutral posture” position. If it is not causing you any issues, it’s probably normal for you!

If you are looking for someone to assist in reversing your posture and increasing general mobility, strength and endurance, I offer one on one and duo Pilates and movement therapy classes, click the link to book. Book a Pilates and movement session

How meditation can assist pain management in my opinion …..

I recently saw a meme going around the therapy social networks, that I quickly resonated with, it showed a great reflection of how it can some times feel when discussing pain science and pain education in general. I mean “Sheriff Woody’s” body language says a thousand words!

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Pain is complex, I guess because humans are complex. At the National Pain Summit in 2010 an explanation for pain was described as “An individual human experience that is entirely subjective and that can only be truly appreciated by the individual experiencing pain”.  I think humans are multidimensional beings and to think of pain as simply being a biological process is limiting. Pain is complex because there is a significant amount of social and emotional suffering that comes along with the physical aspects of pain. Often we talk about treating pain within a bio-psychosocial model, that is a model that understands that pain is a dance between the biological factors, psychological factors such as mood, personality, behaviour and social factors such as culture and familial. To simply just treat the symptoms alone, I have found with my experience, keeps you in a positive loop pattern that only leads to more pain.

Professor in neuroscience Lorimer Moseley (late physiotherapist turned neuroscientist) once said “what are the barriers to really deeply adopting the bio-psychosocial model? Often the application results in clinicians suggesting that pain is in the ‘bio’ and suffering and disability is the ‘psychosocial”. It really is a dance, this is where I feel meditation comes in. I think it is a great adjunct to therapy, I mean we really are mind & body and not just the body so why just treat the body?

Screen Shot 2018-11-09 at 3.57.24 PM

The way I see meditation used as a pain mediator; is that it allows us to see our thoughts & feelings in a non-reactive way. Sure it takes practice to get to this point, but so does everything. To be able to feel discomfort and watch your thoughts, decreases the chance of feeding the symptoms and inevitably increasing them. It allows us to practice being non-reactive to every sensation. This might sound wishy washy but luckily there has been more and more evidence to back this up. In 2016 Cherkin Et-al studied mindfulness and chronic back pain in 342 adults and found that mindfulness based stress therapy resulted in greater improvement in chronic low back pain and functional limitations at 26 weeks compared to usual care.

Another factor that is strongly correlated with chronic pain is fear! Fear avoidant patterns of movement can often keep you in a pain loop = You move with fear, these movements are not bio-mechanically efficient. This causes your body to work in unusual ways likely to cause more stiffness and pain. In the study from Schutze Et-al found that low mindfulness predicts pain catastrophizing in a fear avoidance model of chronic pain.

In my experience meditation allows you to see your thoughts and perhaps the patterns that are so repetitive you may have never realised they are there …. in a loop. I find by seeing this you immediately press the pause button on that loop.

Of course I don’t think meditation alone will alleviate all physical symptoms, however as and adjunct to movement, strength and manual therapy you are definitely giving your body an environment conducive to healing from a mind & body perspective.

Ericka has completed a meditation teacher training and is a daily meditator. Ask her how to include this in your therapy. Meditation.

 

References:

  1. Checkin et al. 2016, Effect of Mindfulness-Based Stress Reduction vs Cognitive Behavioral Therapy or Usual Care on Back Pain and Functional Limitations in Adults With Chronic Low Back Pain. March 22/29. doi:10.1001/jama.2016.2323
  2. Schutze et al. 2010, Low mindfulness predicts pain catastrophizing in a fear-avoidance model of chronic pain. January vol 148, page 120-127. doi.org/10.1016/j.pain.2009.10.030