What outcome, or benefit might you expect from attending Pain Care Yoga classes?

don't lose hope picWell, much like anything, it depends. The answer is rarely straightforward and definitive.

As mentioned in the last post everyone comes in with their own experience of pain,  history,  individual, unique life circumstances. What might be helpful for one, will not likely be the same for another.

Below are a few comments made during a recent class, which illustrates this difference, for each person.

“I slept so much better all last week.”

“I’m not really using my cane anymore. My leg feels stronger, and I have no pain.”

“My back went out last week for a couple of days. I was flat on my back, so I used one of the (breath-awareness-distraction) practices and it really helped me get through it.”

And your back now? – Me

“It’s fine, now.”

“I’m so surprised. Normally I cannot walk around without my shoes on.”

Did you feel pain, while we were doing this (walking exploration, practice)? – Me

“No, I had no pain at all.”

I can’t say what will happen for you, or for another. Most often though, people will begin to experience feelings of calm, safety, less or no pain during class. And, some will begin to transition those responses and feelings into their daily lives.

Like most things in life, what we do, what we practice, we get better at. I would say the same, in this case. If you only practice during our class, for an hour a week, you may not see as much progress, notice as much difference. However, if you do a little, each day, I bet your experience will be similar to these others.

What I highlight to people, from both their comments and experiences is that something changed. To get curious about that, and realize they created the change.

It wasn’t something done to them.

From there, they begin to feel some hope. Perhaps a little empowered and more able to start exploring and learn to self-manage or resolve their persistent pain.

If you’re interested in how this might work for you, the next 6-week series of Pain Care Yoga classes begin at the end of February. I’m also available for one-to-one in-person or ‘zoom’ online sessions and would love to hear from you.

 

What do you do, in yoga classes for people living with chronic pain?

one thingThe 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.

EDUCATION

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.” [1]

PRACTICE

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.

Movement

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.

Breath

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.

Awareness

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.

Relaxation

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.

[1] 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

 

Who Attends Yoga Classes for Chronic Pain? All kinds.

hearts croppedMost people I talk to wonder how yoga might help with their long-term, persistent or chronic pain. So, I thought I might tell you this week a little about who comes to these classes, what we do and why, or the outcomes experienced.

Let’s begin with who attends.

Most people in these classes (or private 1-to-1 sessions) have never done yoga before.

Classes tend to consist of people who don’t turn up in yoga studios, who probably never thought of doing yoga to help with their pain. After all, most of the marketing and imaging around yoga is out of reach for many people, let alone people who have difficulty or experience pain when they move.

Most, are around mid-life; perhaps 45 or older.

The oldest student who’s attended is 78. Most are about 50 – 65 years old. Once in a while someone younger will attend, perhaps in their 30’s. Currently, my youngest client is 13.

What are some of the conditions, or diagnoses they have?

The most common condition is people with persistent back pain and/or those with fibromyalgia. Most often, those with fibromyalgia have had it 20 to 30 years or more. Others have osteoarthritis, rheumatoid arthritis, sciatica, other musculoskeletal pain (hips, shoulders, feet, and neck seem to be the most common). Chronic pelvic pain, is another. Or those who are currently going through cancer treatment, or recovering from it.

What are some of the conditions or diagnoses that often accompany persistent pain?

Most often it’s either (or both) anxiety and depression.  Many suffer from irritable bowel syndrome (IBS), chronic fatigue, sleep issues (insomnia, sleep apnea, etc.), incontinence.

You can see there is such a wide variety and it’s not really ‘yoga’ people coming to these particular classes. Again, from what I know about most, they are people who have tried many other things that haven’t worked for them over the long term or are using yoga as complementary to or integrated with other aspects of their personal comprehensive pain management or treatment plan.

Up next on the blog, we’ll dig into what we do in these classes. I hope you’ll join me.

 

 

You are not too old. It is never too late, for your pain to change.

Yes, it’s my 58th Birthday today!

Like many people my age, we’re not looking so much to get more stuff. Rather, we’re hoping in some small way, we might make a contribution. Help others.

What does this mean for you?

Here’s the thing,

Do you suffer from persistent or chronic pain? Or know someone else who does? Are you tired of finding only short-term relief from pain?

Most people think that pain is inevitable as we age. I used to think so. Now, I know that pain can change. I see it all the time in the people I work with. Science, also tells us this is true. You can learn a bit about my own story of pain and how it changed a little later, but first here’s the deal FOR YOU!

Starting today November 25th until December 2nd, receive 30-40% off my regular pricing. See how you might change what is getting in your way, limiting your life, the contributing factors to your experience of pain. Check this out!

$58 for an initial 90-min session (approx. 40% discount) if you book this week!

$58 for a follow-up 60-min session (approx. 30% discount) if you book this week!
(All appointments to be scheduled between Nov 25th, 2019 and Jan 15th, 2020)

  • Book your first 90-minute session for $58 (regular price is $95)
  • Book a follow-up 60-minute session for $58 (regular price is $85)
  • Book a package of 4 sessions, 1-90 min and 3-60 minutes for $280 (regular price is $335)

BONUS:  You’ll also receive a FREE audio recording of a slow, guided awareness practice. With the usual busy, stressful holiday season soon upon us, this can be used for relaxation, to help guide you into to sleep or rest or just notice what you feel, what you might need on any given day.

GIVE BACK:  I will donate $5 to *Chrysalis House for each session booked, whether a first or follow-up session. Chrysalis House provides a safe and secure shelter to aid in helping and support those affected by domestic violence. Which tends to escalate around the holiday season. Together, helping others.

Email me at info@yogatoolsforlife.com or you can contact me here to book a session or for further information. To learn more about individual sessions, click here.

NEW LOCATION I have a new location for my private 1-to-1 sessions. Various opportunities presented themselves but when I heard about this space called “Comfort Corner” it sounded just right. Thanks to my local community for providing all the leads and contacts in/around the West Ottawa area when I went looking for recommendations. People helping people.

Pain is surely complex. Which is why looking for the ‘thing’ to ‘fix it’ usually doesn’t work.

You truly are unique. Each person I work with comes from a unique background with unique experience and their own history, body, circumstances and environment. We’ll work together in partnership to

  • explore what might be contributors to your pain,
  • how you might change things up,
  • create new patterns of moving without pain,
  • learn to move with more ease,
  • experience how YOU CAN modulate your pain

My goal is to help you learn to ‘be your own best resource. So you don’t have to rely forever upon me, or other health care professionals. You’ll have the tools, resources, information and practices to help you through the inevitable journey of life’s ups and downs. To live a meaningful and purposeful life, no matter your situation or condition of health.

I would love to work with you!

Group Classes are helpful for chronic pain but this 1-to-1 work can make all the difference. Why not see if it’s right for you? Or if you have family, friends or colleagues who you think might benefit, please share with them as well.

Email me at info@yogatoolsforlife.com or you can contact me here to book a session or for further information. To learn more about individual sessions, click here.

*Chrysalis House is a safe and secure 25-bed shelter in Western Ottawa. It is a place where a woman can go to protect herself and her dependants from violence and abuse. In this supportive environment, a woman can focus on her personal needs and choices, as well as on her dependants’ needs.

Taming the Beast, that is pain

Professor Lorimer Moseley explains how pain scientists are making amazing discoveries that can help you understand your pain, the first step in taming the beast.

As you’ll see, pain always involves the nervous system and how your nervous system can be retrained.

  • “How do you know if your pain system is being overprotective?”
  • “How do you retrain your pain system to be less protective?”
  • “How do you know if you’re safe to move?”

Learning a little about pain neuroscience education can be helpful. [1]

What complements this is not only learning but experiencing how YOU can change or modulate your nervous system.

Use the tools yoga has to offer; gentle movement, breath and awareness practices… to soothe and calm the system. To ‘Tame the Beast’.

You can find more information and resources at TameTheBeast.org.

[1] 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.

Yoga and Science in Pain Care

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!

Additional notes:

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.

Yoga Classes for Pain Care

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.

If you’d like details about my Pain Care Yoga Classes click here, or for more information or to register, contact me here.

If you know others who might be interested, please feel free to share this with them, by clicking on any of the share buttons below.

The Evolution of a Practice

SimplifyWhen I used to write about yoga for a local magazine, the numbers of Americans practicing yoga was about 20 million. Today, about 6 years later, that number has nearly doubled, edging up towards to 40 million. Globally, the estimate is about 300 million and the number of over 50s practicing yoga has tripled over the last four years.

People often wonder what this thing called yoga actually is. Difficult to answer in just a sentence but to me YOGA is the exploration, awareness, and response that informs how I (might best) relate to the world inside myself and to the larger world around me.

A large part of this doesn’t involve the physical yoga postures or asana practice, but that’s usually where people begin. It is a good way into the wider exploration. Most, practice on a mat and typically in a group class. Certainly, it’s where I began.

Not knowing anything about yoga when starting out, I first practiced Ashtanga yoga and then when I began teaching it was a somewhat modified Vinyasa practice. Both involve strong, physical, almost gymnastic-like movements linked with the breath. Ashtanga, in particular, is meant to be practiced for 1.5hrs each day, 6 days of the week.

My practice today no longer resembles this in the least. Today, my physical yoga practice is interweaved throughout the day, with broader concepts in the background.

  • Most often it does not take place on my mat.
  • Most often it is less than 30 minutes at a time.
  • Most often it’s a response to whatever I feel might best serve me, at any given time.
  • No special place, clothing, or time.

Which I think might be a helpful way to practice for many who don’t have the time, money, or perhaps ability to get to a studio or gym.

What does this practice look like?

Join me over the next few months and we’ll look at little snippets of yoga, movement, breath practices that can be done in a couple of minutes or combined to make your own personal practice. On your own time, in your own space, that fits into whatever your life demands of you.

Most important to me is to teach people what they can do for themselves. Provide agency. The ability for you to have the tools and the freedom to make choices that enhance your wellbeing and your life.

  • In October we’ll focus on the feet.
  • November will be all about the shoulder joint.
  • In December, we’ll get into the hip joint.

I’ve chosen these particular areas to focus on as they tend to be where problems, pains, issues show up for most people I talk and work with.

You can find me talking about this on Facebook, and Instagram, if you want to follow along.

 

Low Back Pain: GAPS between Guidelines and Practice

bettingrealitycheck

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.

Be-curious-550x344

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.