It’s a distant memory now but my wife and I were recently reminiscing about life before children; a couple of sneaky pints on a Sunday afternoon, watching a football or rugby game uninterrupted in its entirety, sleeping more than 5 hours in any given night (again uninterrupted), not having to squeeze a run in at 5am before the boys wake up or after 8:30pm when the boys are in bed, and holidays. Ah yes, holidays. When the beads of sweat dripping down your face in the airport were due to the over indulging of cheap beer the night before not the stress of getting a buggy and all things baby related through security at Dublin airport at 5:30am for a 7am flight. And in the good old times we even gave skiing a go. The night before packing for our first ski trip pulling the dusty rucksack from underneath the bed, it happened. Up until this point I was in the minority. I was in the 20% of people who had never experienced it. The lucky ones. I had just had my first ever taste of low back pain.
It was the classic mechanism of injury, bent over thrown in with some rotation and pulling and dragging, my enthusiasm and excitement to get my gear packed for the slopes got the better of me. My first thoughts (and words) were: “Oh sh*t!!!”. When I caught an unfortunate, unflattering glimpse of myself in the mirror and noticed the Quasi Modo-like posture I had unknowingly adopted this followed quickly by: “Kate!!!!! Hellllllp”. Even in all my agony I immediately realised how ridiculous that sounded. A physiotherapist specialising in musculoskeletal injuries calling his (then) girlfriend for help. I had been treating people with low back pain, fairly successfully, for a few years up to this. I had been advising them and helping them get back on track following similar episodes so I paused for a moment: Firstly what the hell have I just done? And secondly what would I tell somebody to do in this situation?
“I’ve done my back in”
“I’ve put a disc out”
“I’ve always had a bad back”
“Back pain runs in the family”
These are the things you hear over and over again. Not just during the assessment in physiotherapy clinics but in any daily situation. The myths surrounding low back pain are now well acknowledged as being as far fetched as the ‘5 second rule’, although I still abide by the latter. Things like a disc popping out, bed rest for low back pain, not moving or bending, always having a bad back. These are myths, plain and simple. Two things can happen to a disc. The outer shell (annulus) of it can tear a little or the centre part (nucleus) can protrude out a little bit, or a lot in some cases. In the same way there is no “disc out” it therefore would seem pretty impossible for it to be “put in”. Manipulation can be very effective in helping the spasm and lack of mobility as a result of a possible disc injury but it is not slipping the disc back into place.
80% of us will get back pain during our lives. That’s common. It’s up there with headaches or hangovers. And like headaches and hangovers episodes of low back pain settle and go. 85% will settle between 2-3 weeks and 3 months, usually around 6 weeks. Granted that would be one nasty hangover but point being they do settle. Back pain is so prevalent that it costs the country more than cancer and diabetes treatment combined. And you think how is that? But here’s how: time spent out of work, MRI referral that is often not necessary, insurance claims, surgeries and overnight hospital visits, physiotherapy, poor management, and then recurrence of the problem, but mainly the shear volume of people who will experience low back pain. And where a boozy night is to blame for your resultant run of the mill hangover (2 beers in my case these days) low back pain has its own long list of instigators.
The usual cause is a simple sprain much like you might get if you go over on your ankle. The difference with the back is it is in such close proximity to spinal cord and nerves that its that extra bit sensitive. So it becomes very sensitised and the structures around the injury like muscles and joints tense up to try to protect this recently injured structure. I’ll always remember as a recent graduate hearing Lorrimer Moseley, an Australian pain specialist, speak at RCSI on his ‘Explain Pain’ course and on numerous websites since (TED Talks – have a watch/listen). This painful episode can have a varied impact depending on how it is initially managed, whether there has been any previous episodes of low back pain, that persons perceptions of low back pain, the persons health status and activity levels, the list goes on. There can be a referral of symptoms elsewhere, typically down the back or side of the leg, giving rise to the term we know as ‘sciatica’. But sciatica is not a diagnosis. It is a symptom. Symptoms help us find out what is causing the problem. So what is causing this back pain and the associated sciatica? Yes it may be a disc protrusion. It may be related to some muscle spasm and the adoptive posture developed as a result of pain. This is where a comprehensive examination comes in. The history of the patients problem and the examination should tell us all we need to know and if an MRI scan or further investigation is needed.
But is a scan needed? Scans are very expensive, they can take a long time to arrange and also whilst in the scanner itself. They’re more readily available now around the greater Dublin area but many parts of the country are still poorly serviced by MRI availability. If you’re Paul O’Connell and you break a finger nail there’ll be a scan organised immediately as you leave the pitch at the Aviva Stadium. For the rest of us mere mortals we need to be thinking is it really necessary. And all too often the answer is no. Through a thorough physical examination and listening to your story of how the problem came about your physiotherapist should be able to get a fairly good picture of what’s going on in there. The MRI scan should only confirm this. Also you have to remember that a scan isn’t going to solve the problem. You’ll have been waiting maybe 2 weeks to get the scan privately, you wait again to get the result and it reports back saying some degenerative changes at a couple of levels (some wear and tear) and you’re still no further on regards getting it right. And here’s the real sickener: Often times the scan won’t even correlate with what we’re seeing anyway. The perfect example is disc degeneration. Someone with low back pain gets an MRI scan which shows some degeneration (what a horrible word). But it may have nothing got to do with THEIR pain. It probably doesn’t. 90% of people with NO back pain will have similar wear and tear when MRI scanned. 50% will have bulging discs. Remember they have NO pain. But back to the patient with pain. He’s told he’s got wear and tear and gets an image in his mind of crumbling bones, discs jutting out putting himself at risk of paralysis if he moves a certain way. They become terrified to do anything. They don’t move to protect themselves, the muscles tighten, the joints aren’t being put through a range of movement so they stiffen up. All of a sudden a person who probably just had a little sprain unrelated to any wear and tear has had the problem catastrophised simply by the language and terminology used. In these instances scans in fact do more harm than good. It needs to be explained clearly to people. Wear and tear is normal. It happens, like grey hair or male pattern baldness and it’s usually not that big of a deal. It’s how we manage it.
Too often people want a quick fix of some massage or a quick manipulation. And it’s often effective. I do it myself but the underlying cause needs to be addressed. That cause could be something simple and obvious but sometimes needs to be pointed out. It may be lack of fitness, overweight, deconditioned, poor lifestyle choices like poor posture or eating habits. It’s these issue that are often the reason people get recurrence of low back pain or longstanding pain that doesn’t settle. If the underlying problem doesn’t change then how can the resultant outcome change? Like any injury it’s a lot easier to stay injury free than return from injury. So even if you’re not in pain with your low back I’d argue doing some maintenance work to stay that way. Sitting at our desk, commuting long hours every day is just not helpful so unfortunately that probably means dedicating some time to negate the influence of these flexed bent positions.
Now I should say that sometimes an MRI scan is absolutely warranted and indicated. If the problem doesn’t fit a typical pattern or is not settling down in the typical manner then it is certainly justifiable to eliminate any serious pathology. And if alarm bells are ringing suggestive of something sinister then it’s time to get to the hospital ASAP as an emergency. That’s not scare mongering, just good advice. The kind of things to be looking out for are:
- Bladder or bowel problems: so issues with loss of control passing or holding urine.
- Loss of feeling or sensation in the legs, feet or back passage.
- Weakness in the legs causing stumbling
Orthopaedic and neurosurgeons will nowadays try all conservative routes before this. A recent study suggests that long term results comparing surgery and physiotherapy for some spinal conditions are actually quite similar. In that case I know what I’d be choosing. The problem being that ‘quick fix’ again that we’re all after. Much like how we want to lose all that weight now. We want to be able to run a marathon now. We want our business to be an overnight success now. And we want rid our back pain now. If a quick fix was offered on any of the above we’d take it and for some reason surgery had gotten an untrustworthy reputation as a quick fix for low back pain. Eh what about the complications? What about the fact that nothing has changed with what probably caused the original episode of back pain, i.e. maybe weakness, poor postural awareness and control, the patient being unfit. And as with weight loss or a new years resolution exercise plan the quick fix often does not work. If the conservative route fails or if the situation is seen as a medical emergency then surgery can of course be considered but like other orthopaedic surgeries like a anterior cruciate ligament repair or knee replacement, the surgery is only as good as the rehabilitation that follows it.
So back to my bag packing. Yes I probably just sprained a small ligament in my low back and got some muscle spasm. I took some of my own advice which turns out to be difficult to do and tried to keep moving. I took some pain medication for the first couple of days skiing and stopped things from stiffening up and didn’t let it hamper my first ski holiday. But I’m in that 80% now and I’m also statistically more likely to get more episodes of low back pain. I can try reduce the likelihood. I can try staying fit and active but as I sit perched at the kitchen island writing this I catch another unfortunate, unflattering reflection of my old buddy Quasi Modo staring back at me from the dark kitchen window. And as I sign off our ten week old is awakening for another nappy change, getting heavier by the day as I bend and rotate to pick him up. It’s just a matter of time really but at least we know what to do now.
Rob McCabe MISCP
MSc Physiotherapy, BSc Sport Science and Health, MSc Sports Physiotherapy, Post Grad Dip Ortho Med
You can find more information at http://www.mccabephysiotherapy.com
McCabe Physiotherapy, Orchard House, Moorefield Rd, Newbridge, Co. Kildare
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