Do you know that you can experience a HUGE amount of pain, yet have no damage or injury in your body?
Have you ever heard of phantom limb pain? It’s when someone experiences pain, yet they don’t even have the body part? Think of someone who’s maybe had their arm amputated but still feels pain there. How can that be?
Or maybe you’re someone who has been diagnosed with fibromyalgia. No obvious damage or injury can be found yet absolutely, you feel pain.
Do you know the reverse is also true? You can have NO pain and yet have ‘damage or injury’ in your body?
Have you ever found a bruise on your body yet had no idea how it got there? Or maybe you broke a bone playing one of your favorite sports but didn’t really feel pain, until you got to the hospital? There was obviously tissue damage, yet no pain. At least at first, perhaps.
Maybe you’re someone who has disk degeneration, yet no pain. According to this study (brinjikji et al 2014) if you’re 60 years old, 88% of people whose back has been imaged will show disk degeneration, yet experience NO pain. If you’re up to 70 years of age, it’s up to 95% who have what looks like damage or injury and yet has NO pain.
When you have a headache, think of a really, really painful headache, … do you think you have something broken or damaged in your head? Likely not.
So why do we think that way about other parts of our body?
Pain is weird, for sure. And complex. And our understanding of it does not always match with what’s going on. Often, we are confused by it, don’t know what to do about it and just live with it.
Don’t get me wrong. You NEED pain. Otherwise you would likely not survive. You need a mechanism to tell you something is up and you need to attend to it.
It’s the persistent chronic pain that seems to be the trouble. In Canada and most places around the world, 1 in 5 people live with it. If it were an easy fix, we would have done so by now. Two areas that the evidence tells us seem to be most helpful are: understanding pain and movement. We’ll cover both.
Well, there is more to it but if you’re curious to know how you might change, how you can influence your own experience of pain, I’d love you to join a new 6-week online program starting July 22, 2020.
Advantages of this being online?
anyone can take it in the privacy of their own home,
at their own pace
all the content is yours to keep forever, and
I’ve made it affordable and accessible so anyone can enroll. $25 week, for 6 weeks (both a payment plan and options are available).
If you or someone you know might benefit, click the link below for all the details.
I could really go on and on about breath, from many different angles and actually have been sent down the rabbit hole for a few days now wondering how I might approach this, in a single blog post.
Our breath, the in-breath and the out-breath happen quite naturally, right? Of course, they do. It is one of the most important things necessary to our survival. We do not have to think about it. It is just one of the many wonderous systems in our body, working behind the scenes.
However, if you look at how a baby breathes, and how many of us older folks breathe, you might notice a difference. How in babies and young children it almost seems like their whole body moves when they breathe. How their big, soft bellies expand with each inhale. For us, often, not so much.
There could be a whole mess of reasons, but the one I’ll explore here is one you’ve perhaps been exploring over the past week.
Muscular tension might be involved when we hold our breath, or when it doesn’t flow so freely.
Generally, muscles and tissues may become strained, fatigued over time if they are recruited, or over-recruited, ‘switched on’ a lot. We may not be aware of this, particularly if ongoing over a long period of time. It often becomes our usual ‘pattern’ rather than what might be a responding or releasing (and relaxing) as required.
There are also some areas of the body where this tension might get in the way of a full, easeful, ‘natural’ breath we see in a baby. I think of the stomach or belly area for one. How many people unconsciously hold or constrict in this area for a multitude of reasons? This, which happens to be the area containing your primary breathing muscle, the respiratory diaphragm. Or might someone hold tension unconsciously in their pelvic floor (diaphragm) muscles, again for a variety of reasons? I think of all those ‘core exercises’ we’ve been told are good for us or how often women socially, culturally, ‘suck in their stomach. Or perhaps you’ve been told to do kegels at one time or another, or hold, strengthen or tighten up your pelvic floor muscles. Which may be useful. Or maybe not.
Both diaphragms are meant to move with each breath yet with tension and tightness in one or both, might this change how we breathe?
Holding tension might not allow for a full, deep breath such as when our respiratory diaphragm moves down, creating the in-breath. Maybe, we hold tension in the pelvic floor, without realizing it and again, not allowing for optimal breath.
Now, think about what is more important to our body, to our brain, but breathing. And how this regular intake of oxygen not only provides nourishment our body needs to survive, but it also forms or influences our physiological state. For instance if we are under threat, or even perceived threat there are immediate changes to our physiology, including our breath, that takes place to aid in our survival.
Which is all great when we’ve broken a bone, need to pull our hand away from fire, stay clear of toxic fumes or something similar. Back in the old days, we would need all our senses, these sensations, to help us stay clear of dangerous predators like tigers and the like.
What happens now though, is often we are unaware of:
1. The threats (real or perceived) that we encounter on a daily basis. These aren’t likely threats like running from tigers, but threats in terms of our relationships, our jobs, our finances, our communities, our environment. How much of the news do you see, threatens your sense of safety? Does this create a sense of tension, stress, holding of your breath perhaps, in your body?
2. The response of your nervous system and subsequent physiology that accompanies this. You may have read that stress is not good for the immune system, for your mental health, etc. but there are also effects on other areas or systems that occur including your pain system. If pain is meant to protect you, yet you ‘feel’ threatened, stressed, and tense might that turn UP the volume of pain? Have you ever noticed a correlation (not saying cause, here) in your stress levels and your pain?
Conversely, how might a sense of safety, turn DOWN the volume of pain? Even a few simple words from a parent to a child such as “you’ll be okay” often turns down a pain response.
Can we learn to notice our breath and what that might tell us about how we feel?
Can we find a breath that is supportive for us, when it’s called upon?
Can we find a breath that is supportive for for us, when we need rest, find calm, sleep?
There is no right or wrong in this.
Rather, can we find a responsive, flexible breath that supports us for whatever it is we’d like to do? To live in an optimal state of health? As a first step, can be begin to notice this at all?
Personally, attention to breath and subsequent practices has had the most influence I find, when working with people who experience persistent pain. Time and time again. Though as Shelly rightly points out “the practices must be individualized to meet the unique needs of the person.” Telling people to take big, deep breaths, may not be ‘the answer’ or ‘the fix’ for everyone which is often what I see out in the main stream media. Suggesting there is some kind of ‘ideal’ breath, for all people, at all times.
I was looking at this tree (pictured above) in my back yard at lunch time today. It sways and flows. Appears strong, yet supple. Not rigid, brittle, tight or constricted. Takes in nourishment, gives back some. Might we be like this tree … A breath in. A breath out. Responding as need be, in any given moment to what life is asking of us.
I’ll be diving into this in more detail with information, a little bit of research and experiential practices in Week 4 of my upcoming online ‘Creating New Pathways‘ course. Want to learn more?
Interested to learn more about this thing called ‘yoga therapy’? Some FAQ’s plus links for ways yoga therapy can help, information for healthcare providers, where we’re at in terms of current research and yoga, yoga therapy.
The second question people often ask me about Pain Care Yoga classes, after “who is it that comes to these classes” described here, is “what do you do in them”?
Pain is never just about one thing. You want to know what’s wrong. How you’re going to fix it. And how long it’s going to take. And rightly so, as having long-term pain often changes everything for you and how you live your life.
When it comes to pain, however, it is usually not that simple which is why searching for ‘the thing‘ usually doesn’t work in the long-term. Particularly if you’ve had pain for a long time. Which doesn’t mean to say that it can’t change. It can. We know what can help to bring about change, the best practices research points to.
Two key aspects, education … and movement, are important. So that’s what we do in these classes.
Some kind of education piece, usually at the start of the class, is provided. I only spend a few minutes on this, but it’s important to do so. One of the most common things I see with people in pain is the fear of moving. If I can help you to understand why it might be safe to move and why it’s important to do so, that’s a good place to begin.
“Current evidence supports the use of pain neuroscience education (PNE) for chronic musculoskeletal (MSK) disorders in reducing pain and improving patient knowledge of pain, improving function and lowering disability, reducing psychosocial factors, enhancing movement, and minimizing healthcare utilization.” 
Then, you practice. You get to experience how you might move, with guidance and guidelines, to learn what’s right for you. Which often won’t be the same as others in the room.
This is not a typical yoga class with sun salutations, downward dogs, lunges, forward folds, backbends. It is not even what I would call a ‘gentle yoga class’. Yes, we use slow, gentle movements. Yet, sometimes you might begin by just imagining the movement if you don’t yet feel safe to do it. Or you might practice it in your mind, plan out how you might go about it and if it feels right for you. It is always your choice to do or not do anything presented in class. You always get to decide how to move, how far to move, by using a slow, mindful exploration along with guidelines and principles utilized.
Most movements are fairly simple and modifications are always available. You’ll experience a lot of repetition, and rhythmic movements. Movements that cross the midline of the body. Movements that challenge your brain as well as challenging your body. You, anyone, can really begin wherever you’re at. With what’s right for you.
There will always be some kind of breathwork or a breath awareness piece in the practice. Again, it’s not so much about controlling the breath, rather what you might notice about your breath. How breath can be an indicator of your physical and emotional state at any given time. Also, learning how breath can help to bring about change to your nervous system, physiology, which can then change your experience of pain.
Like breath, awareness is key. So often when you are in pain the last thing you want to do is pay more attention to your body. But in fact, this paying attention is your guide to changing pain. It is in this noticing that you can begin to explore what the signals (or sensations) you feel might be indicating, what might be your unique contributors to pain, what might be the reasons for flare-ups. This practice is not only about noticing your body in class but then also paying attention to your whole self in your environment, in the larger world you live in.
There are many reasons, purposes and benefits to practice relaxation techniques. In most yoga classes this is done at the end of class. Though we’ll also do some kind of formal relaxation practice at the end, relaxation or creating a state of calm is facilitated right from the start.
It is when you are in a place of safety, when you are calm and relaxed, that change is likely to occur. It is this place of calm (a parasympathetic state) when you might first experience a change in your pain. Without this, it’s no different than trying to stretch, exercise, push through and strengthen your pain away, which seems not to work out so well.
If you’re interested in learning more, have any questions or would like to sign up for the next series of classes starting at the end of February, please get in touch here. I’d love for you to experience, how you might learn to change your pain. Or, if you prefer a one-to-one session, information can be found here.
 Adriaan Louw, Kory Zimney, Emilio J. Puentedura & Ina Diener(2016)The efficacy of pain neuroscience education on musculoskeletal pain: A systematic review of the literature,Physiotherapy Theory and Practice,32:5,332-355,DOI: 10.1080/09593985.2016.1194646
Unhelpful beliefs about LBP are associated with greater levels of pain, disability, work absenteeism, medication use and healthcare seeking. Unhelpful beliefs are common in people with and without LBP, and can be reinforced by the media, industry groups and well-meaning clinicians.”
The purpose of the editorial (made free due to popular demand, read it here) and the infographic is to “identify 10 common unhelpful beliefs about LBP and outline how they may influence behavioral and psychological responses with pain”.
The authors are also “calling on clinicians to incorporate these into their interactions with patients.”
This is so important. It’s why I always include a touch of education and information as part of my Pain Care Yoga classes. When people are in pain, it’s difficult to understand why it might be safe to move, how important it is to move and how movement “doesn’t mean you are doing harm – FACT #5”.
I hope these FACTS will bring some curiosity to your beliefs. I hope you might consider what you believe and how they might influence your experience of pain, either positively or negatively.
Sometimes, however, information is not enough. I, we, can give you all the ‘FACTS’ but often until you experience that you CAN move without pain it’s difficult to change beliefs.
As called for in the editorial, I am personally committed to bringing evidence-informed information and education to the people I work with and hope to provide a new experience to get you moving again, with confidence.
Foster NE, Anema JR, Cherkin D, et al. Prevention and treatment of low back pain: evidence, challenges, and promising directions. The Lancet 2018;391:2368-83.
Buchbinder R, van Tulder M, Oberg B, et al. Low back pain: a call for action. The Lancet 2018;391:2384-8.
 Louw, Adriaan & Zimney, Kory & Puentedura, Emilio & Diener, Ina. (2016). The efficacy of pain neuroscience education on musculoskeletal pain: A systematic review of the literature. Physiotherapy Theory and Practice. 32. 1-24. 10.1080/09593985.2016.1194646.
How might we blend yoga with science to provide pain care to people? A new book just released provides a way forward.
“Our vision is for this book to improve care for people living in pain, whether acute or chronic pain. We believe health care professionals and yoga therapists can enhance care through deeper understanding of pain, science and evidence-informed interventions. We also believe that professionals can enhance their work through integrating yoga concepts, practices and philosophies. As such, this book is meant to bridge yoga, pain science and evidence-informed rehabilitation … and will inform those committed to helping people with this largely undertreated issue that causes so much suffering in the world.” – Preface, Yoga and Science in Pain Care; Edited by Neil Pearson, Shelly Prosko, Marlysa Sullivan
The first chapter by Joletta Belton is about the “Lived Experience of Pain” highlighting to me the need to listen to, acknowledge and consider first, the person and their experience.
“The authors provide an integrated, in-depth understanding of how yoga therapy can be incorporated within a modern understanding of pain as an experience. The book encompasses perspectives from people living with pain, summarises research progress in the field, debates theories of pain and pain management, considers the many different yoga practices, describes pain biology, self-regulation and examines breath, body awareness, nutrition, emotions and response to pain, and above all, integrates concern for practitioners and people in pain as humans sharing an intangible experience together. The authors write about how yoga therapy can provide a uniting and compassionate approach to helping people learn to live well.”
– Bronwyn Lennox Thompson, PhD, MSc, DipOT, Postgraduate Academic Programme Leader, Pain and Pain Management, Orthopaedic Surgery and Musculoskeletal Medicine, University of Otago, Christchurch, NZ
There are a lot of yoga books on shelves these days. Yoga for this, yoga for that. You name it; it’s being written about. The trouble with this and certainly when talking about pain is the approach is about the condition, the problem, the illness or disease. What’s often left out is the person. Which may be one of the reasons why we fail in helping people.
After all, your pain is not the same as my pain. Not only is the physical aspect different, my body different, my genetics, my structure. Almost more important is the rest of ‘me’ that’s different from ‘you’.
My life history is different from yours. My environment is different from yours. My stressors are probably not your stressors. My understanding of pain probably differs from yours. My expectations, beliefs and thoughts about my pain will be different from yours. My social structures, friends, family, work-life will all be different. So how might we believe we can just apply this ‘fix’ to everyone who experiences pain? It just doesn’t make sense, when you think about it. Particularly when we understand that pain… is… complex.
We, therefore, should look to explore and be curious about all the things that might be contributing to your particular experience of pain. Similarly, individualize the care, tools, techniques and practices with what research tells us might be useful, to change your pain.
You may have had pain for years. Like 30+ years or more. Still, there is an opportunity for change based on what we know about pain and how it works. There is much still to learn but we can change the nervous system, We can change the brain. We can change physiology and most likely all three of these have been changed if your pain has been ongoing.
Pain can change. There is hope. I will keep saying this over and over and over again …
If you’re the type that likes read and learn about this yourself, order a copy of the book, here.
If you’re the type that would like to learn from me in person or in a class setting with others, check out my updated schedule for the fall, here. New classes starting in September!
Joletta Belton, as noted above, writes a blog “My Cuppa Joe” about the lived experience of pain. Among other things, she is a speaker, educator and advocate for people in pain. You can read her blog, here.
Bronwyn Lennox Thompson also writes a blog “Healthskills: For health professionals supporting chronic pain self management.” An exceptional resource for information, research, and discussion. You can check it out here.
My desire for this update is that in some way it might inspire, be of benefit and most importantly, bring hope to you or someone you know who lives with chronic pain.
Approximately 1 in 5 people in Canada suffer from chronic pain, with costs to the Canadian healthcare system between $47 billion and $60 billion a year – more than HIV, cancer and heart disease combined. One might say that my desire, my passion, is in helping people who feel stuck, in despair and without hope in terms of their lived, unique, experience of chronic or persistent pain.
About 5 years ago, I started studying pain. What pain is (or is not), what might contribute to it and what the current evidence and research tells us. My interest began as a result of my own experience with chronic pain, which dates back a few years prior. Well, actually it began about 2010 or 2011, so almost 9 years ago now.
A year ago I decided to undertake training Neil Pearson offered to various regulated health professionals (doctors, physios, massage therapists, etc.) and yoga teachers, combining pain neuroscience education along with yoga practices and philosophy. The first workshop of the certification process he offered in Ottawa last year, happened to be part of the first module in a certified yoga therapy training program, also here in Ottawa (I subsequently applied to this program as well, and will start the second year of the 2-year IAYT Certified program next week).
Fast forward one year and I’m now certified to teach Pain Care Yoga classes!
WHY DOES THIS MATTER?
Neil trains both medical professionals and others in non-pharmacological pain care in the hopes of bringing knowledge, expertise and evidence-based practices into local communities. He is a physical therapist, a Clinical Assistant Professor at University British Columbia, and a yoga therapist. He has been a consultant with Doctors of British Columbia since 2013, to develop and implement clinical pain management continuing education. He is past Director of Pain BC, and the founding Chair of the Canadian Physiotherapy Pain Science Division.
His goal is “to help people living in pain and to assist others with the same desire to serve. We must shift many paradigms. Our views of pain, the people in pain, and the role and effectiveness of non-pharmacological pain care are mostly outdated.”
My goal is to help serve this purpose as well, by bringing Pain Care Yoga to local communities.
The good news about pain is that it can be modulated, there is hope, and as Professor Lorimer Moseley (probably the most cited pain researcher globally, based in Australia) now says “recovery is back on the table”. We know enough now about chronic pain that we can change lives.
In small group classes (or individual sessions), I hope to play my small part towards helping some of the 20% of our population in Canada who live with persistent pain.
Each time I meet with someone, listen to their experience, offer current explanations about pain, help them learn to move in safety with more awareness, attention and ease, it is clear to me WHY THIS MATTERS.
My classes start mid-April in Stittsville, with private
sessions also available.
I 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) studyhe 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 🙂 )
“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.
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.
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.
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?
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.
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.
“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.
My hope is perhaps you’ll come to see for yourself there are promising directions for those disabled and suffering from low back pain.
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?
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
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
Advice and education about the nature of their pain;
Reassurance that they do NOT have a serious disease and their symptoms will improve over time;
Encouragement to stay active and continue with usual activities.
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.
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.
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.
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.
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.