Summer has officially begun and soon many will be on their long-anticipated holidays. Most likely, it will involve some travel. And at some point the dreaded ‘are we there yet?’ You might think it to yourself or maybe your little travel companions repeat the phrase. On the hour. Time seems to drag. on. forever.
Why is it we dread the getting to, and coming back from, our trips?
Sure there can be unexpected delays or surprises that inevitably happen. But typically it’s the thought of sitting in our vehicle driving for 4, 8, or 12 hours to our destination. Or being crammed into the airplane for hours on end. Uncomfortable, to be sure. Not only being seated for so long but also waiting to eat on someone else’s schedule or getting to the bathroom when the need arises.
Most of us sit, for hours, all day long. Why then, does it feel different or more noticeable when we’re traveling? In an airplane, it’s not so easy to move around, to shift in our seats, when discomfort arises. In our cars, perhaps it’s a little easier with more room and not so many eyes watching us.
On most any day, we tend to listen to the hunger and thirst signals our body sends us, while other ‘discomforts’ such as simply moving, tend to be ignored. Why do we respond to some and not to others?
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.
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.
The bad news is you may have or know someone that is experiencing chronic or persistent back pain. The good news is, there is a way forward.
Yesterday, three important papers about back pain published in the Lancet (one of the world’s oldest and best known general medical journals) were referenced in the The Guardian, The Telegraph, the BBC News and the Daily Mail . So current evidence-based information, at last, making its way to the public domain.
In briefly reviewing the papers (published March 21, 2018), the key points for me are these:
“Low back pain is now the leading cause of disability worldwide.
“Prevention of the onset and persistence of disability associated with low back pain requires recognition that the disability is inseparable from the social and economic context of people’s lives and is entwined with personal and cultural beliefs about back pain.”
“Most low back pain is unrelated to specific identifiable spinal abnormalities,”
“Globally, gaps between evidence and practice exist, with limited use of recommended first-line treatments and inappropriately high use of imaging, rest, opioids, spinal injections, and surgery. Doing more of the same will not reduce back-related disability or its long-term consequences.”
“Recommendations include use of a biopsychosocial framework to guide management with initial nonpharmacological treatment, including education that supports self-management and resumption of normal activities and exercise,…”
Thank goodness this is getting the attention it deserves so it can help people who need it most. And that’s a LOT OF PEOPLE.
Why now, finally? I think it’s gaining traction due to spiraling health care costs along with the opioid crisis that is so prevalent.
Over the next while I’m going to break down and comment upon some of the points and principles presented in the papers, as many form the basis of my work. In the meantime, if you care to read the papers yourself they can be found here.
Lorimer Moseley, one of the world’s top researchers on pain continues to make the related point that people need an understanding of what pain is and what it isn’t, as he does with a touch of humor in his TEDx Talk in 2011. Professor Moseley is most known, however, for publishing 260+ papers on pain science and his continued work as Professor of Clinical Neurosciences and Chair of Physiotherapy at the University of South Australia.And one of many leading the charge globally in what he calls a Pain Revolution.
A huge paradigm shift is required as understandably, information about what works to treat back pain and what doesn’t is confusing. It seems counter-intuitive to ask people who are in pain to ‘just move more”. As the latest interviews I’ve listened in to with Lorimer, he states that with what we’ve learned ‘recovery is, back on the table’. There is hope. As I mentioned earlier, there is a way forward.
I talk about this all the time with family and friends … who often have a hard time believing what I describe as it is a change from what we have believed for most of our lifetime.
But, if we really truly want to get people out of this pain cycle (and I will say most any pain cycle) we need to help with the understanding of what the evidence shows and how to best work with it. This will also require huge shifts in our public policy, etc. as stated in the Lancet papers.
“These potential solutions include focused strategies to implement best practice, the redesign of clinical pathways, integrated health and occupational interventions to reduce work disability, changes in compensation and disability claims policies, and public health and prevention strategies.”
So come along for the ride if you or anyone you know is experiencing chronic or persistent low back pain (or any pain, really). With 1 in 5 experiencing chronic pain of some kind, unfortunately, you won’t have to look too far.
People often sit at their desk, laptop, TV, or plugged into a smartphone with their earphones in. Listening to music, podcasts, videos on YouTube, working, or whatever.
As an experiment, the next time you put your earphones on, don’t ‘listen’ to anything except your breath.
It may not be as noticeable if you’re on the bus, driving, in an airport or a similar noisy environment. But, still, I think you’ll find it to be … telling.
How are you breathing?
Are you breathing fluidly?
Is there equanimity on the inhale and exhale. Or is one shorter or longer than the other?
A pause in between may be good. But do you find that you’ve actually stopped breathing? As in not breathing altogether of course, but that your breathing is not fluid. Easy. Continuous. That there is a long pause, perhaps, between the two. That you fail to begin the inhale, until long after the exhale.
Why might that be?
How do your neck muscles feel, while you’re noticing ‘this’ breath?
How does your torso or trunk feel?
How does your abdomen/belly feel?
Do you notice or feel anything at all?
Do you sense anything?
What might this noticing, this awareness tell you?
In the meantime, try this.
Inhale, and exhale, along with the shape below. Expansion, contraction.
I’m curious to hearof your experience.
I can say for sure, I noticed a few things about my own breathing patterns.
When there is quiet, what do I hear?
(Though we’re in the midst of a cold winter, I find I can ‘listen’ more clearly to my breath when swimming or floating in water, similar to listening with earphones in as above. Or if I submerge myself in bathwater. So choose what’s best for you, whatever might be your season.)
Consider the ways you need to use and move your body every day.
Depending on your life, how much you move throughout the day may be fairly limited or alternatively, you might go through a whole range of movements.
Do you work in an office? Sitting, walking, reaching, writing might be some of the things you do in a day. I suspect sitting, is a primary one. Do you work as a plumber? Your movement needs are different than the office worker. As are what a doctor, teacher, hairstylist, service worker, etc. will be, who are often on their feet much of the day.
What you need to ‘train for’ is different than what anyone else needs to ‘train for’.
What a person needs who sits at a desk all day, is different than what a parent with toddlers needs, versus what a teacher might need.
We sometimes get into trouble when we’re doing exercises, that don’t always or altogether correlate so well to what’s actually required in our life. If you’re exercising for basic fitness and enjoyment, that’s fantastic. That in itself is an achievement. But perhaps you might consider adding more to the mix if you’re someone who also experiences pain, fatigue, etc.
This is important:
If you’re hitting the gym every day, building strength and stamina but suffer from low back pain because you’re also sitting in a chair for 8 hours a day, perhaps you need to train differently or add something to your training routine.
If you are the most amazing yogi but suffer from hip strain or other pain symptoms because during the rest of the day you’re standing on your feet, perhaps you need to look at what you’re training for.
If you’re out on the golf course getting your exercise and fresh air daily, but cannot ‘do, or manage’ the rest of your life, perhaps you need to do something else as well.
What happens all too often is the hour of exercise we get at the gym, yoga studio or out on the golf course doesn’t quite support all the rest of what we need to do in our day.
If you need to sit, train as best you can so your body can adapt for this.
If you need to stand, train what’s required in order to stand a lot.
If you are the golfer, train for whatever it is you need to do, besides golf.
But how can you do this and where to find the time?
It’s not always easy, but you can learn to build it into your day. It doesn’t always have to take another hour going to the gym, paying for a babysitter, driving through the snow. There are simple tools, you can use. Anywhere, really. That don’t take up a lot of time.
I’m going to challenge you to change things up this week. Whatever you think you should be doing, (in a movement, in your posture) whatever you’ve been told to do… do the opposite.
As an example, while you’re sitting during the day:
If you have a tendency to hold yourself rigid, perhaps with your shoulders pulled back, chest puffed out front, sitting up nice and tall, as some would say ‘good posture’, allow yourself something different. Perhaps slump a little, let the upper back round a little, feel as if you can soften the area between your collar bones, let your belly be soft and full when you breathe. RelaxI’m not saying this is what you need or you should sit this way all day. But try it for a few minutes and notice what you feel.
If you tend to be someone who is generally in a slumped position when sitting, try the opposite. Feel your sitting bones on the bottom of your chair, perhaps even pushing them into your chair slightly. Think about sitting tall, imagining your head feeling light above your shoulders, it lifting towards the ceiling. Collarbones wide, shoulder blades down your back. Notice what you feel.
Though this is only one example. You might try this way of being, or doing, in a multitude of ways.
In yoga, do you always exhale when forward bending and inhale on the reverse? Try changing it up and see what you feel. What do you notice?
Experiment with doing the opposite of what you think is right for you, what you’ve been told is right for you and see how it goes. If you like, comment below so we can take the conversation further.
I’ve also learned it seems we may have been ‘wrong about stretching‘ insofar as we’re not really stretching or lengthening muscles. At least not as much as we once believed. Rather, we’re changing our response to a stimulus via the nervous system.
Our brain is naturally going to respond in a protective manner to anything it perceives as dangerous. If we are trying to re-train flexibility or just movement in the body and do so with strong, forceful pressure or stimulus … the brain/body will react by saying … stop! No! Don’t go there. It will send a (pain) signal to safeguard our movement.
However, if we move in small incremental ways within a safe and pain-free range of motion, the nervous system will react by saying … this feels okay. Safe. I’m happy to explore this.
This is a somewhat simplified way to explain all that’s going on, but it’s a starting point we can work from. We can even begin by just imagining movement and still create changes in the brain and our nervous system. So we can, really, start anywhere.
By learning to pay attention, moving in a way that allows your nervous system to adapt and create new patterns while it feels safe, you will make progress.
Look at a baby or a young child for a few moments and you’ll notice they make all kinds of movements, in all kinds of ways. I watched a video yesterday and thought back to the crazy, wild, wonderful things we did as kids with no thought or consideration about how to move our bodies.
Look at old or aging people and what do you notice? I suspect it would be unsteadiness, stiffness, feet shuffling, bending or moving with great care. For me, the word rigidity comes to mind.
Rigidity – Not able to be bent easily, not easily changed, not willing to change opinions or behavior.
What happened between then and now, new and old? What does the future look like in terms of your body’s ability to get around in the world?
Today I noticed a question on a Facebook site, “If there was one thing you could change about yoga what would it be?”
One of the responses was “Having people talk about flexibility the moment I mention I teach yoga.”
Flexible – able to change or be changed easily according to the situation; able to bend or be bent easily without breaking.
You could also add – the ability to be easily modified, willingness to change or compromise.
People always link yoga with flexibility which can be true. I want you to think of flexibility, however, in a slightly different context than the ‘bendy’ flexible yogi.
You don’t need to have a ‘bendy’ body to do yoga or live your life. However, you DO want to be able to manage the task at hand, whatever that might be for you personally.
You want to have options, multiple ways of navigating rather than narrow lines, restrictions, or rigidity.
How can you do this? How do you go from feeling stuck and/or experiencing chronic pain to feeling flexible in this context?
That you have options in your body, in your life?
Follow along… and we’ll find a way to bridge the gap.
(To receive future blog posts, please scroll to the bottom of the page and click the SUBSCRIBE button)
What I continue to learn is we really can’t be absolutely sure, about any of this. But, stay with me …
As soon as I discover something to share or write about on a blog post, it may soon be out of date. Though research leads us in the most reliable way we know at any one time, it’s only as good as the next study. Knowledge changes, books get re-written.
There is the constant discovery of what we thought we knew, what we’re now learning and what’s yet to come. As in life itself.
As I stated before, pain is indeed very complex. I’m not sure anyone knows with certainty what causes and therefore eliminates back pain, for instance. But I have seen it dissipate almost immediately and over time for those who once believed it cannot, or never will.
For me personally? Today’s x-rays and ultrasounds will likely show arthritis and chronic inflammation / plantar fasciitis still exist in my feet. I do know, however, that my feet (legs and hips) have dramatically changed by working with awareness, changing movements and therefore re-patterning my nervous system over a relatively short period of time. That, and a whole host of other changes to sacroiliac (SI) joint pain which no longer exists, shoulder impingement being resolved and hip bursitis… almost there on it as well.
So where does this lead me, or you, or anyone else?
Are you resigned to thinking it ‘just has to be’ this way?
What is it you REALLY want to be able to do?
Many people I speak with and work alongside are/were just like me and don’t know what information or skills they can learn and use to help them move better, sleep better, feel better.