That never-ending pain in the a**

hip-painfulI originally posted this on the Yoga and Movement Research Community Facebook group earlier in the week and then realized I should probably do so for my own readers.

Hip pain, SI joint pain, osteoarthritis of the hip, scoliosis, etc. often come up for discussion as a topic of pain and injury and there’s new research that may be helpful to others experiencing these conditions or symptoms.

“Gluteal tendinopathy, often referred to as greater trochanteric bursitis or greater trochanteric pain syndrome, has a prevalence of 10-25% and is experienced by one in four women aged over 50 years. The disorder presents as pain and tenderness over the greater trochanter and often interferes with sleep and physical function. The level of disability and quality of life is equivalent to that of severe hip osteoarthritis, and effective management strategies are required.”

I’ve just been listening to a podcast, which led me to the guest’s (Tom Goom, physiotherapist) blog post, which led me to a new (May 2018) study he references, which then led me to some other information about hormones.

First, I find it interesting, that gluteal tendinopathy has commonly been misdiagnosed.

“GT typically presents as pain over the greater trochanter (the bony lump felt at the side of your hip). Symptoms may spread into the outside of the thigh and knee. It is commonly misdiagnosed as hip joint pathology, ITBS, sciatica or as being referred from the lumbar spine. GT is a good example of how clinical knowledge has progressed in recent years. Initially it was thought of as inflammation of the trochanteric bursa – a fluid filled sac that sits over the trochanter. However as research developed we realised 2 rather important things. The bursa may not be the issue and there isn’t really any inflammation. Later the condition was termed Greater Trochanteric Pain Syndrome (GTPS) but further research has enabled us to be more specific with the diagnosis. Bird et al. (2001) examined MRI findings of patients with GTPS, they found that nearly all patients had evidence of Gluteus Medius Tendinopathy. Swelling of the bursa was present in just 8% of cases and did not occur in the absence of gluteal tendinopathy.

The primary pathology of Gluteal Tendinopathy is most likely an insertional tendinopathy of the Gluteus Medius and/ or Gluteus Minimus tendons and enlargement of the associated bursa.”

Second, a study published in the BMJ (May 2010) shows its both education AND exercise which results in greater improvement at both 8 and 52 weeks (as compared to corticosteroid injections or ‘wait and see’ approach) in Gluteal tendinopathy. Again, how education is an important piece of the pain puzzle. Most often people experiencing pain do better with both education and movement, according to current research.

Third, right at the end of the podcast, Tom briefly mentions how hormones may play at part. Interesting again, as this is very common presentation for women who would be experiencing menopause. As noted above, 1 in 4 women over the age of 50 (myself included 🙂 )

In this systematic review and meta-analysis of 102 studies, published in the British Medical Bulletin, Jan 2016 they conclude “the role of hormones in tendinopathies is still controversial.”

However,

“The continuous modulation of female sex hormones during the menstrual cycle affects the composition of tendon collagen, because the connective tissues express receptors for both estrogen and progesterone. This leads to a clinically relevant condition in relation to physical training and musculoskeletal performance of female athletes.” 

Key points for me through all this is that education is a key component so “the patient” has some control. Our current systems typically leave out self-efficacy or agency of a person and rather encourages a dependence, passivity and ‘have someone else fix it’ situation. Knowing you have some understanding and influence over your health rather than the usual doubt, uncertainty and fear can go a long way.  Though this does involve engagement, commitment and doing the work.

On the topic of hormones, well let’s hope that future researchers will see the need to account for such differences rather than using only males for most health-related studies. I understand it’s difficult to do given the cyclic nature, but surely it makes a difference.

If you’re interested in this, suffer from on-going pain in your a**, or are curious about how hormones may play a part I encourage you to read further. Or, you can always comment below to discuss.

  1. Running Physio blog post: New study is a LEAP forward. He’s written a few over the last month, you may want to check out.
  2. BMJ (June 2018): Education plus exercise versus corticosteroid injection use versus a wait and see approach on global outcome and pain from gluteal tendinopathy: prospective, single blinded, randomised clinical trial.
  3. British Medical Bulletin (Jan 2016): Hormones and tendinopathies: the current evidence

Low Back Pain: GAPS between Guidelines and Practice

 

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Continuing with the second of three papers recently published in The Lancet regarding Low Back Pain. What guidelines are already in place, what’s actually occurring in practice and suggested solutions going forward.

What’s striking to me is the

clear evidence of substantial gaps between evidence and practice, that are pervasive

A few years after delving into this, I am still scratching my head how far behind we are in our medical and clinical practice given the evidence. Yet, I’m hopeful that as more and more of this gets into the public domain, much-needed momentum will begin to close the GAP. Particularly with the crisis we find ourselves in, the growing epidemic of opioid use which is literally, killing people.

What are the treatment guideline GAPS, as outlined in the paper?

Below are

study results of clinical practice and highlights the disparity between ten guideline recommendations and the reality of current health care.

Guideline Message: Low back pain should be managed in primary care.

Practice: in high-income, low-income, and middle-income settings, people with low back pain present to emergency departments or to a medical specialist.

Guideline Message: Provide education and advice.

Practice: in high-income, low-income, and middle-income settings this aspect of care is rarely provided.

Guideline Message: Remain active and stay at work.

Practice: in high-income, low-income, and middle-income settings, many clinicians and patients advocate rest and absence from work.

Guideline message: imaging should only occur if the clinician suspects a specific condition that would require different management to non-specific low back pain.

Practice: although such specific causes of low back pain are rare, in high-income, low-income, and middle-income settings, imaging rates are high.

Guideline message: first choice of therapy should be non-pharmacological.

Practice: surveys of care show that this approach is usually not followed.

Guideline message: most guidelines advise against electrical physical modalities (eg, short-wave diathermy, traction).

Practice: worldwide these ineffective treatments are still used by the professionals who administer physical therapies.

Guideline message: due to unclear evidence of efficacy and concerns of harm, the use of opioid analgesic medicines is now discouraged.

Practice: these medicines have been overused in some, but not all, high-income countries; low-income and middle-income countries seem to have very low rates of use.

Guideline message: interventional procedures and surgery have a very limited role, if any, in the management of low back pain.

Practice: these approaches are widely used in high-income countries, little evidence on their use is available for low-income and middle-income settings.

Guideline message: exercise is recommended for chronic low back pain.

Practice: clinician treatment preferences and health-care constraints limit uptake.

Guideline message: a biopsychosocial framework should guide management of low back pain.

Practice: the psychosocial aspects of low back pain are poorly managed in high-income, low-income, and middle-income settings.

As you can see, what’s recommended is not what’s being offered to people for treatment.

Though first line care is meant to be non-pharmacological,

a study from the USA showed that only about half of people with chronic low back pain are prescribed exercise. In Australian primary care and in the emergency department setting in Canada, the most common treatment is prescribed medication.

Then, there are the rates of imaging, even though it has a limited role to play (see previous post).

39% in Norway, 54% in the USA, 56% in Italy as three examples, presenting patients to emergency rooms are given imaging.

Even worse, opioids. Though data for effects of opioids for acute low back pain are sparse,

one study showed that they were prescribed for around 60% of emergency department presentations for low back pain in the USA.

And,

More than half the total number of people taking opioids long-term have low back pain though NO randomized controlled trial evidence is available about long-term effects. Well, we can see some of the short-term effects taking place across our countries at the moment.

In terms of surgery, which has “a limited role for low back pain”,

studies from the USA, Australia and the Netherlands show frequent use of spinal fusion.

So the waste to our healthcare system is apparent, but the bigger cost is what’s happening to the people who are provided these treatments that have shown to have little success. They seem stuck in what seems a never-ending loop of pain.

Key messages:

“Guidelines recommend self-management, physical and psychological therapies, and some forms of complementary medicine, and place less emphasis on pharmacological and surgical treatments, routine use of imaging and investigations is not recommended.

Little prevention research exists, with the only known effective interventions for secondary prevention being exercise, combined with education, and exercise alone.”

Where do we go from here?

“Promising solutions include focused implementation of best practice, the redesign of clinical pathways, integrated health and occupational care, changes to payment systems and legislation, and public health and prevention strategies.”

Current guidelines need to be utilized which we clearly see, they are not.  There needs to be better integrated education of health-care professionals including a change to the clinical-care model. Revamping the “current models of health-care reimbursement, which reward volume rather than quality”. Integration of health-care and occupation interventions so we can get people back to work and back to their lives. Changes to compensation and disability policies. Finally, public health interventions to change public’s beliefs and behaviors.

Which brings us to the last of the 3 papers, Low back pain: a call for action, up next on the blog.

Low Back Pain – What works and what doesn’t, according to the research.

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Previously I wrote about the first in a series of published papers in the Lancet regarding the global burden of disability caused by low back pain and why we need to pay attention. You can read it here.

The second paper, “Prevention and treatment of low back pain: evidence, challenges and promising directions” contains a lot of information so today I’ll begin with prevention and treatment while the next blog post will further explore current guidelines vs. what’s actually utilized in the global medical community.

My hope is perhaps you’ll come to see for yourself there are promising directions for those disabled and suffering from low back pain.

I. Prevention

Most of the widely promoted interventions to prevent low back pain do NOT have a firm evidence base.

A surprising statement, isn’t it? These include what you have likely been told over and over again to do, yet evidence of their success is not there. Strategies about workplace education, no-lift policies, ergonomic furniture, mattresses, back belts, lifting devices. How often have you heard about most or many of these in terms of how we might prevent low back pain?

What then, seems to work?

II. Treatments

First, is the recommended use of a biopsychosocial model.

I suggest most of the general public has never heard of this term or model of care. I surely didn’t just a couple years ago when I was first started to dig into the overarching problem of chronic or persistent pain that affects so many people.

What is this? Well, as often defined it encompasses “a dynamic interaction among and within the biological, psychological, and social factors unique to each individual.”  My emphasis on the ‘unique to each individual’, as that’s turning out to be an important piece of the complexity of pain.

Second, greater emphasis is needed on

  • Self-management
  • Physical and psychological therapies
  • Some forms of complementary medicine,

Along with less emphasis on

  • Pharmacological and surgical treatments.

What’s actually being utilized in our clinics?

Surprisingly, the treatments with less emphasis and effectiveness = pharmacological and surgical treatments.

Countries such as Denmark, the USA, and the UK do have guidelines around this. They are supposed to utilize exercise and a range of other nonpharmacological therapies such as massage, acupuncture, spinal manipulation, Tai Chi, and yoga.

Clinicians are meant to provide people with

  1. Advice and education about the nature of their pain;
  2. Reassurance that they do NOT have a serious disease and their symptoms will improve over time;
  3. Encouragement to stay active and continue with usual activities.

Self-Management

I understand even the notion of engaging in movement and exercise is difficult for people who are experiencing pain. How do you keep active when you are in pain? How much does advice, education, reassurance really help? People typically go to their health care providers and want something to ‘fix’ the problem. Not more advice. However, evidence shows this does help. And, evidence shows that the pharmaceuticals and surgeries we’ve come to rely on, don’t. In the long-term, particularly. If they worked, we wouldn’t find ourselves in this predicament.  Understanding that you have a part to play, in getting better, is critical. 

Movement or Exercise Therapy

Going back to the problem of trying to move, when you’re in pain. Something that people may or may not be familiar with is the term graded exposure. Basically, it means you start where you can, and gradually, over time, work to increase your overall capacity.

I tell my clients it will help to do even the smallest of movements. Use your imagination and even just visualize movement if you must, but you CAN start somewhere. Move your feet, or hands, or arms an inch, if that’s what you can do today. Just begin.

It has been shown to be useful if you can tie in your exercise or movement with something you want or need to do, rather than just some kind of exercise that is not motivational for you.

It’s not really so much WHAT you do, but that you DO something.

“Since evidence showing that one form of exercise is better than another is NOT available, guidelines recommend programmes that take individual needs, references, and capabilities into account in deciding about the type of exercise.

I use tools that yoga offers and work to help keep clients joints moving in all the many ranges of motion they might need in their life. This does not mean they need to have a life-long love or commitment to yoga.

Yet, yoga does offer an important first step of building awareness and subsequently using gentle movement, breath awareness, and tools to ‘ease into a movement’ that may have be feared in the past. People can learn to calm their nervous system, work in a safe pain-free range of motion (or not increase pain). From there we work to build stability strength and power in whatever it is they want to do … be that swimming, walking, biking, skiing, playing with kids, sitting at a desk all day. Whatever it is they want to do in their life.

Passive Therapies

It should be noted that some guidelines DO NOT recommend passive therapies, such as manipulation or mobilization (think chiropractor, massage, acupuncture). Some guidelines consider these short-term options, optional. The same goes for other passive treatments received in a physical therapists office like ultrasound, nerve stimulation, etc.

Though these passive types of therapy may help to temporarily feel better, they often have many returning again and again, becoming dependent on them for relief. Much of the current research shows the need to get a person ‘involved’ in the treatment. Get their brain and nervous system participating in movements or other practices, so passively ‘being worked on’ might not be a long-term solution.

Psychological Therapy

Guidelines also recommend Cognitive Behavioral Therapy (CBT), progressive relaxation and mindfulness-based stress reduction (MBSR).

This again is where yoga can play a part in terms of relaxation. I’ll often incorporate strategies from MBSR when working with clients.

Pharmacological Treatment

Guidelines now recommend pharmacological treatment ONLY following an inadequate response to (the above mentioned) first line non-pharmacological interventions.

Paracetamol was once the recommended first-line medicine for low back pain; however evidence of absence of effectiveness in acute low back pain and potential for harm has led to recommendations against its use.

Health professionals are guided to consider oral non-steroidal anti-inflammatory drugs (NSAIDS), taking into account risks …  and if using, to prescribe the lowest effective dose for the shortest possible time.

Routine use of opioids is NOT recommended, since benefits are small and substantial risks exists…

The role of gabaergic drugs, such as pregabaline, is now being reconsidered after a 2017 trial showed it to be ineffective for radicular pain … guidelines generally suggest consideration of muscle relaxants for short-term use, although further research is recommended.

Surgery

The role of interventional therapies and surgery is LIMITED and recommendations in clinical guidelines vary.

Recent guidelines DO NOT recommend spinal epidural injections or facet joint injections for low back pain… they DO NOT seem to provide long-term benefits or reduce the long-term risk of surgery and have been associated with serious adverse events.

Benefits of spinal fusion surgery … are similar to those of intensive multidisciplinary rehabilitation and only modestly greater than non-surgical management.

UK guidelines recommend that patients are not offered disc replacement or spinal fusion surgery for low back pain.

For spinal stenosis … patients tend to improve with or without surgery and therefore non-surgical management is an appropriate option for patients who wish to defer or avoid surgery.

So why the GAP between evidence and practice?

Stay tuned and we’ll look to see how this is played out and why it’s imperative that we change it.

 

 

 

Low Back Pain – Extremely common, complex in nature and most often, not treated effectively

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Last week I wrote briefly about a recently published paper in the Lancet, picked up by the news in the UK, here, here, here, and here. Today, I’ve seen an article in the USA. So, far, one report that I can find, in Canadian news.  One headline from Monash University in Australia goes so far to say:

Global burden of low back pain – a consequence of medical negligence and misinformation

As mentioned, I said I would break down why I believe this is so important. The first paper (three in the series) is “What low back pain is and why we need to pay attention”.

Why should all of this matter to you? Why do you need to pay attention?

The median 1-year period prevalence globally in the adult population is around 37%, so chances are you or someone you know is affected.

And, what’s even more important, is

the way we have been treating people isn’t working.

“Low back pain (LBP) is now the number one cause of disability globally.”

There are a LOT of people who experience chronic or persistent low back pain.  On a purely personal note, I would say it is the most prevalent ‘problem’ people tell me about when they turn up at my yoga classes.

“Rarely can a specific cause of low back pain be identified; thus, most low back pain is termed non-specific. Low back pain is characterized by a range of biophysical, psychological, and social dimensions that impair function, societal participation, and personal financial prosperity.”

In other words, it’s complex.

Of course, there is always a need to rule out those cases where there is specific causes.

“but, this is for less than 1% of those presenting with LBP. Known causes may include vertebral fracture, axial spondyloarthritis, malignancy, infection, or cauda equine syndrome (very rare).”

So if any of these are suspected by presenting symptoms, a clinician is well advised to do testing, imaging, etc. for what are often referred to as ‘red flags’.

If these are ruled out or if you’re not suspect for these specific causes, what then?

“Most adults will have low back pain at some point.  It peaks in mid-life and is more common in women, than in men.”

“Low back pain that is accompanied by activity limitation increases with age.”

“Most episodes of low back pain are short-lasting with little or no consequence…”

“But recurrent episodes are common and low back pain is increasingly understood as a long-lasting condition with a variable course rather than episodes of unrelated occurrences.”

It’s highest in working age groups so the effect to the workforce is impacted. People unable to work, earn income, the possibility of early retirement. “In the USA, LBP accounts for more lost workdays than any other occupational musculoskeletal condition”.

Then there’s a person’s identity. Consequences such as loss of independence, ability to fulfill expected social roles can be impacted. Common themes of worry and fear are identified, along with hopelessness, the strain on families, social withdrawal, job loss, and there’s the navigating through continual healthcare encounters.

Most studies underestimate the total costs of LBP, but the economic impact is comparable to other high-cost conditions like cardiovascular disease, cancer, mental health and autoimmune diseases.

Most cases are resolved within 6 weeks, however, there are risk factors for recurring episodes. For people with other chronic conditions like asthma, headaches, diabetes. Those with poor mental health are at increased risk, etc. As one example, a study of Canada’s population with 9909 participants, found that “pain-free individuals with depression were more likely to develop LBP within 2 years than were those people without depression”.

Lifestyle factors are also at play. Smoking, obesity and low levels of physical activity are associated, although independent associations remain uncertain.

Which brings us back to it being complex. There are multiple contributors, “including psychological factors, social, biophysical, comorbidities and pain processing mechanisms.”

We can see the complexity when there is a continual increase of those affected, an increase in our health care expenditures and by the recent opioid crisis that is literally taking people’s lives.

It also seems whatever we’ve been doing in terms of treatment doesn’t seem to be working.

Why is that and what needs to be changed?

Tune in next week… where we’ll get to the second paper, “Prevention and treatment of low back pain: evidence, challenges, and promising directions.”

Note:   For those interested, all references/studies can be found in the Lancet paper, here.