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Chronic Back Pain Treatment Options

On a daily basis I see clients that have or have had Non-Specific Lower Back Pain, or back pain that is caused through trauma. Individuals that come in for treatment are usually;

  • Afraid to move – based on preconceived notions which we will discuss later.
  • Have a belief that they have “put their back out” and that this is something that they will need to live with for the rest of their lives.
  • There is a heavy belief that surgery may be a good solution to reducing back pain.

As the science around back pain has developed dramatically over the last several years, the dogma around it has been slow to catch up. Unfortunately, these long held beliefs will persist with individuals due to factors that are uncontrollable by allied health professionals. Factors such as anecdotal evidence given to patients from a relative or friend that is held to a high degree, self-confirming biases – “I moved a certain way and the pain increased”, or poor self-efficacy around exercise.

The truth is that most of the science points to the fact that surgical intervention has a very poor history of reducing pain, and even worse at returning mobility to a patient. Surgeries such as spinal fusions have around 5-10% confidence rate in pain reduction. Degeneration, ruptured discs, bulging discs, arthritis, and narrowed discs have been clearly shown to not be the source of chronic back pain, in fact ruptured and bulging disks have shown the ability to repair themselves with conservative treatment. Even with all of this evidence these are the most common reasons for surgical intervention. Another factor that can impact an individual for long after surgery is that chronic pain can develop from the surgical site, this is unfortunately the case in up to 60% of post-surgical cases. Factors such as nerve impingement, that can cause pain radiating to the lower limbs, as well as other factors can see the re-operation rate be has high as 20% in the first year. A large factor that can make surgical intervention a reoccurring issue is that the fact that by decompressing the joint space, the bony surfaces then lack the mechanical loading that is needed for bone health. This can lead to further degeneration that can lead to complications at the surgical site or surrounding tissue.

Unfortunately, back and cervical pain can be one of the hardest pains to live with. Our brain has an innate drive to protect the central nervous system for survival purposes. Pain signals from the tissue surrounding the spine can and often do drive several protective mechanisms. One being protective muscular guarding, this is an increase of tension of the muscles to reduce movement and decrease the impact of injury on the spinal cord. This to can impact the intrinsic supportive musculature around the spine, impacting spinal roots and causing pain in areas wide spread inferiorly. This can lead to individuals becoming restricted through movements which cause pain and fearful of movement. In most cases this pain is not related to tissue damage but can cause an individual to avoid movements which further contributes to a ramp up of pain and muscular guarding.

Conservative treatments that are targeted at mobility and strength have been shown to be the most effective with short and long-term outcomes. Decreasing the pain loop that can quickly be imbedded in the brain and increasing strength to support stability around the pelvis, and vertebra have been clinically proven to increases positive patient results. Unfortunately, long term neurological pain tends to require long term treatment, as the pain signals become imbedded like a memory. This does not mean that the brain can’t forget this, but it takes an intrinsic motivation from the individual to self-manage. Neurological change needs to be practiced daily (the more the better) to actually benefit the individual, just like learning a new skill. If you want to learn the piano, or ride a bike, practicing once a week or fortnight will unlikely cause a neurological change. Consequently, if you want your brain to unlearn pain, you will need to practice, practice, practice!

If you or someone you know is afflicted by back pain you have many options before you think of surgery. If the pain has been present from a short amount of time between one day to less than twelve weeks (acute stage) a physiotherapist would be one of your first ports of call. During the first stages of injury manual therapies conducted by a physiotherapist are likely to have their best outcomes. By going the extra step and receiving concurrent treatment from an Exercise Physiologist, outcomes are likely to be increased and time afflicted are likely to be greatly reduced. If the pain has been present for more than three months (chronic), an accredited exercise physiologist would be best suited to help. Unfortunately, after the first acute stage is over and pain has become chronic, this is where the neural loop that we discussed becomes more impactful, and hands on treatment provide little if any benefit. At Absolute Balance we can help to guide you on the best treatment options, no matter what stage of injury you are at.

 

Jordan M Woods

(B.Sc. Exercise, Sport Science, and Rehabilitation, GradDipSc.

Exercise Physiology Rehabilitation)

 

References

Bredow, J., Bloess, K., Oppermann, J., Boese, C., Löhrer, L., & Eysel, P. (2016). Konservative Therapie beim unspezifischen, chronischen Kreuzschmerz. Der Orthopäde45(7), 573-578. doi: 10.1007/s00132-016-3248-7

Longo, U., Loppini, M., Berton, A., Laverde, L., Maffulli, N., & Denaro, V. (2014). Degenerative changes of the sacroiliac joint after spinal fusion: an evidence-based systematic review. British Medical Bulletin112(1), 47-56. doi: 10.1093/bmb/ldu030

Martin, B., Mirza, S., Comstock, B., Gray, D., Kreuter, W., & Deyo, R. (2007). Reoperation Rates Following Lumbar Spine Surgery and the Influence of Spinal Fusion Procedures. Spine32(3), 382-387. doi: 10.1097/01.brs.0000254104.55716.46

 

Spinal Cord Injuries

Spinal cord injuries can be sudden, unexpected and can impact a person’s life significantly. Statistics show that one person per day has a spinal cord injury, most of them being traumatic (transport related) and a 1/3 occur due to falls. Males account for 80% of all spinal cord injuries and a higher prevalence is seen between the ages 15-24 years old. The spine is made up of multiple segments cervical, thoracic, lumbar and sacral. Spinal cord injuries can occur at any level of the spine and the complications that occur due to injuries are quite complex.

Spinal cord injuries can be classified as complete or incomplete, meaning there can be partial preservation of sensory and or motor function below the neurological level affected or there can be a complete absence of sensory and motor function. Impairments due to spinal cord injuries are very broad depending on the site and level of injury (lesion) within the spine. For example, a complete injury (lesion) at the first lumbar vertebrae can result in paraplegia which results in complete loss of leg function, meaning that this client could experience loss of bladder and bowel control, sexual dysfunction and likely to be wheel-chair bound but still have upper body sensation and movement.

When assessing patients with spinal cord injuries we look into Dermatones and Myotomes using the ASIA scale which helps to determine the extent of the spinal cord injury using grading from A-E. Dermatomes are areas of skin that is supplied by a single spinal sensory nerve root, each of these nerves send sensation and pain from a particular area of skin straight to the brain.  Myotomes relate to groups of muscles that a single spinal nerve innervates, which tells us what muscles and movements are impaired.

  

 

Exercise Physiologists can complete these assessments and design our exercise programmes specifically tailored to help patients improve quality of life, independence and mental health based on their client’s individual goals of rehabilitation and their impairments.

 

Dominique Mitchell

(B.Sc. Exercise, Sports, & Rehab Science; Grad Dip. Exercise Rehabilitation)

References

Australian Institute of Health and Welfare. Spinal cord injury, Australia 2014-15 [internet]. 2018; AIHW cat. No. INJCAT 193. Available from: https://www.aihw.gov.au/reports/injury/spinal-cord-injury-australia-2014-15/contents/summary

Kirshblum, S., Burns, S., Biering-Sorensen, F., Donovan, W., Graves, D., & Jha, A. et al. (2011). International standards for neurological classification of spinal cord injury (Revised 2011). The Journal Of Spinal Cord Medicine, 34(6), 535-546. doi: 10.1179/204577211×13207446293695

Winter, B., & Pattani, H. (2011). Spinal cord injury. Anaesthesia & Intensive Care Medicine, 12(9), 403-405. doi: 10.1016/j.mpaic.2011.06.008

 

 

Flip Your Thinking

One of the major contributing factors to assisting people to overcome injury is demystifying their diagnosis and beliefs until a point is reached that they believe they will get better. Empowering clients through positive language and interactions can result in vastly different outcomes to negative language and interactions. Our families and social networks along with trusted industry professionals sometimes unwittingly plant the seeds for failure attempting to relate and sympathise. Just because you have a back injury and your best friend had a back injury does not mean your rehabilitation will take the same path. One of the most debilitating things that we see as practitioners is the belief that something will take longer to get better than the pathology suggests, due to a belief created by someone the client knows who happened to have similar injury and ‘it took them’ a year or more to get better.

So how do you convince someone who has established unhelpful beliefs around their injury that the people they trust (their nearest and dearest) could be wrong. Typical approaches have seen a science focus with facts and numbers being used to demystify injuries, however ominous sounding language can further confuse patients with an increase in the belief that they have a diagnosis and pathology, and therefore what they are experiencing is to be expected. Patients believe they have been diagnosed with so many problems it should take a ‘long time’ to get better. If as practitioners, we can change the way we empower patients and assist with unhelpful beliefs we move from being part of the problem to part of the solution. Encouraging patients to move rather than encouraging them to avoid. In this way the ‘emotional’ energy expenditure that has been focused at not moving can be rerouted to get moving and get better simply by changing the way we deliver information.

When dealing with a friend or family member we can adopt the same approach using positive language to encourage whilst empathising with the situation. Simple changes can be very powerful, make plans for ‘when’ you are better, not ‘if’ you get better. If you have had a similar injury think of helpful advice ‘I am back playing golf’, not ‘it took me two years to play golf again’. ‘It felt better when I started walking’ not ‘it hurt to bend’. Simple changes can be very powerful switch your thinking from the negatives to the positives empowering recovery and resilience rather than reliance and entrenchment.

Ingrid Hand – Exercise Rehabilitation Manager – Accredited Exercise Physiologist (ESSA)
(BSc – ExHealthSc, GraddipSc, ExRehab MSc, HumMvt)

Armstrong, MJ., Mottershead, TA., Ronksley, PE., Sigal, RJ., Campbell, TS., & Hemmelgarn, BR. (2011). Motivational interviewing to improve weight loss in overweight and/or obese patients: a systematic review and meta‐analysis of randomized controlled trials. Obesity Reviews, 12(9), 709-723.

Chronic Pain

Chronic Pain

Musculoskeletal injuries are extremely common, however, sometimes the pain one experiences after an injury can hang around for a substantial length of time. This is known as persistent pain or chronic pain and affects 1 in 5 Australians. Working with musculoskeletal rehabilitation, I have seen many people experience chronic pain after an injury. Chronic pain seems to be a new concept to many as we are taught that pain goes away when tissues heal after an injury or illness, which is not always the case. It can be extremely frustrating and debilitating for people to feel like their symptoms are not improving after months of rehabilitation. In this blog I am going to answer some of the most common questions I get asked by my patients experiencing chronic pain.

 

  1. What is the bodies normal response to pain and how is chronic pain different from this?

Pain is the body’s warning system when you are sick or injured. It is a protective mechanism that forces you to act. This system has been important in humans’ ability to evolve and survive. This type of pain is acute pain (nociceptive pain) and is a reaction to a noxious stimulus. Acute pain is generally simple to treat and tends to fade away as you begin to feel better.

Chronic pain is pain that persists after the body should have healed, usually about three months. This pain may not be warning you of damage occurring in the body so there is no longer a direct link between pain and harm being caused by the (preceding) injury or disease.

 

  1. Why does chronic pain occur?

Chronic pain occurs because of changes to the nerves or nervous system. The nervous system can continue to fire danger messengers to the spinal cord which the brain can interpret as pain, even if the tissue itself is fully healed. Chronic pain is a condition in its own right because the changes in the nervous system are now unrelated to the original diagnosis or injury, meaning the amount of pain you experience does not reflect the amount of tissue damage present.  

 

  1. Are you saying the pain is all in my head?

When pain persists, the body’s alarm system becomes more sensitive. All pain is produced in the brain however all pain is real. With chronic pain, your brain is operating on faulty information about the condition of your tissues. The pain is normal- but the processes behind it are now altered.

 

  1. Should I exercise with chronic pain?

Our bodies are made for movement. Movement provides the nervous system and brain feedback about the body and the environment. This helps to normalise the nervous system which reduces your sensitivity to pain. Movement also helps with many other systems of the body; it helps to keep the heart and lungs healthy, improve muscle and joint function and improves mood and mental health. Graded exercise programmes; where people slowly increase the amount of general exercise they perform to re-condition their muscles, have been shown to help people with persistent pain. With people that are highly de-conditioned or fearful of movement these types of activities can be very difficult to perform due to aggravation of pain therefore is it important to consult a health professional when commencing a new exercise program.

 

  1. What is pacing and how does this help with chronic pain?

Pacing is a pain management strategy used to improve an individual’s tolerance to a task. Many people with chronic pain make the mistake of completing a task until they experience pain or a flare of symptoms in which can result in significant rest periods or the belief that they cannot do this task without pain. With pacing, you select a task you want to do more of, such as going for a walk and figuring out a baseline for this. For example, you might be able to walk for 5 minutes before you begin to experience some pain, however can comfortably complete 3 minutes of walking without any symptoms therefore three minutes would be your base line. From here, you would begin with completing only bouts of three minutes of walking with planned progressions. Time is often a good progression measure. With the walking example above, you could add 30 seconds to each walking bout whilst monitoring your symptoms and slowing increasing your baseline. It is important not to panic if you have a flare up – as people with chronic pain typically have highly sensitive pain pathways, it is almost impossible to avoid not having a flare up at some stage.

 

  1. What are the treatment time frames for someone with chronic pain?

This is different for everyone. With chronic pain, people can go weeks or months without a flare up and then re-experience symptoms. The key with chronic pain is all about self-management. During this process it is very important to educate yourself on your pain and understand your treatment plan in the short and long term.

 

For more information about managing with chronic pain, consult an exercise physiologist at Absolute Balance.

 

Tayla O’Halloran
(B.Sc. Exercise Physiology)
Accredited Exercise Physiologist (AEP) (ESSAM)

 

 

References:

Pain Management Resources

painmanagement.org.au/apma-support/pain-training.html

 Explain Pain | David Butler, Lorimer Moseley | OPTP