The World Health Organisation defines health as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.” So what’s this concept of “wellness” all about? Well, wellness is basically healthiness… It’s the active process of becoming more aware of your health and making positive changes towards leading a healthier, more fulfilling life.
What is wellness?
The concept of “wellness” can often be a dirty word in healthcare circles, as it has long been associated with antiscientific or pseudoscientific ideas… But that depends on what wellness means to you. To us, wellness is health. It’s living a healthy and fulfilling life, and taking responsibility for your own health. We’re taking ownership of the word wellness and are going to strive to clean up its reputation!
Go on then, how?
As an evidence based clinic, we rely heavily on what research tells us is effective for managing conditions or symptoms, and as such the treatment protocols that we utilise can vary quite dramatically depending on what the latest high quality research says is effective. We don’t sell long treatment plans, and you shouldn’t buy into one either- it’s impossible to know that someone will need 12 treatments to get you better when they first start seeing you- instead, a short course of treatment should be proposed and that should definitely include a review appointment where you discuss your progress and determine if you should be discharged from care. We collect patient reported outcome measures to ensure that we do not over or under-treat our patients, and this provides us with an opportunity to identify how effective the treatment is that we’ve provided,
(P.S. We monitor how many treatments our patients receive on average- it’s just 5 appointments over a 3 month period!)
We promise you that as an ethical healthcare clinic we will never offer you ineffective, unnecessary treatment.
Why does wellness matter?
If you were lucky enough to be born in the UK, chances are you’ll have encountered the NHS once or twice. The NHS is a fantastic system for taking care of us, but it is overstretched, overburdened and not coping. When it was established in 1948, life expectancy for men was 66 years old, and for women, 71. Today those figures are 77.2 and 81.5. Over the past 60 years, the proportion of all deaths caused by cancer has risen, from 16.9 to 27 per cent. It took 50 years for the UK population to increase from 40 to 50
million between 1898 and 1948, but in just 24 years the population will increase by 10 million – and hit 70 million in 2029, according to the Office for National Statistics. Simply put, there’s more of us, we’re living longer, with more diseases and more complex health needs than ever before. Our poor NHS can’t cut it.
The NHS will always be there for us when we get sick- but how about we work a little harder to stop ourselves needing it in the first place?
More and more people are recognising a need to take responsibility for their own health and are striving to lead a healthier lifestyle. This can be through small steps, such as reducing your alcohol intake, not smoking, regularly exercising or you might take it a little further, with bespoke nutritional programmes, chiropractic care to optimise performance and move well, in addition to regular care to address the stresses and strains we put our body through on a daily basis.
An holistic approach to health
Ahh, “holistic”. Another dirty word. Or is it? Philosophically, holism is described as “the belief that the parts of something are intimately interconnected and explicable only by reference to the whole.” From a medical perspective, it’s characterised by “the treatment of the whole person, taking into account mental and social factors, rather than just the symptoms of a disease.” Doesn’t sound so bad to me- as humans we do need to consider the person as a whole. Someone with back pain doesn’t just have back pain- they have a problem that’s preventing them from going to work (social issue), that’s causing them anxiety (psychological issue), that’s limiting their ability to walk (physical issue) and no doubt a whole host of other problems. So it would be churlish to only consider the physical issues- that’s probably not going to get them truly better, particularly for those with high anxiety levels as there’s a whole host of research that tells us they need more specific management to help with their back pain. We need to acknowledge their
needs as a whole. We need to ensure we address all these aspects in order for them to recovery.
We also need to consider the why behind their pain. For example, a smoker will report higher levels of pain perception than a non-smoker. That’s an environmental issue. So an holistic approach would aim to tackle the smoking also (not least for the hundreds of health benefits you see from being a non-smoker) and encourage you to take active steps towards leading a healthier lifestyle (there’s that wellness
definition popping up again!)
This is what we aim to provide for our patients- not just addressing the physical symptoms but ensuring that all your health needs are met.
So when we talk about taking an holistic approach to wellness, that suddenly doesn’t sound like such a bad thing, does it?
It may or may not surprise you to find out there’s a lot of misleading information about back pain out there- more specifically, about what to do when back pain strikes and how to prevent it from recurring. This has not only over-simplified how to treat back pain but also lead to some weird and wonderful rehabilitation strategies.
Let’s bust a few of these back pain misconceptions.
1. Sit-ups will help improve your spinal health
Did you know that the average sit-up causes compression of the lower back that almost exceeds the safe limits set by the National Institute for Occupational Safety and Health (the unified set of manual lifting recommendations based on the convergence of medical, scientific, and engineering points of view which helps determine safe work practices)
Physical fitness does have an impact on our spinal health, but it is more important that we are getting fit in the right way. Studies have shown that increasing abdominal strength through sit-ups causes stress on the discs in our back and compresses the lumbar spine- enough for researchers to conclude that sit-ups may cause problems in almost anyone.
2. “Lift with your knees, not your back”
Have you ever tried to do this? Ever tried to do it all day long? It’s almost impossible to do this every single time we go to lift something. Forget the old squat technique, instead, the way you lift should depend on what you’re lifting, where you’re moving it to, your own build, how many items you have to lift and so on.
For more information on how to lift correctly (and give your knees a break) click here.
3. Strong muscles, strong back
Not so, my friends. Muscle strength doesn’t help us predict who will or won’t get back problems, and focusing too much on strength instead of stability will be sure to cause problems. Instead, focus on muscular endurance (i.e. how long your muscles can sustain an activity for). Remember, muscles have three main properties: flexibility, strength and endurance. Any issues that results in a lack of flexibility, strength or endurance will be enough to stimulate the nerves within your muscles and start telling your brain that something’s wrong. What’s the end result of that? Pain.
4. Tight hamstrings and unequal leg lengths cause back problems.
These types of issues are often given as easy diagnoses to simplify the cause of a patients’ complaint. Don’t be fooled. Some studies have shown that in athletes with ‘tight’ hamstrings, these muscles function almost like springs, to help jump higher or run faster. It rather appears that tight hamstrings aren’t the issue, it’s how well these tight hamstrings can cope with stretching that determines whether or not you’ll have back pain. Studies have found that people with chronic back pain tend to use their hamstrings instead of their gluteal muscles to extend the hip, which can increase the amount of force on the spine during squatting- correcting this is going to be a fundamental aspect of care.
Interestingly, back pain also wasn’t found to be definitively linked with leg length discrepancies even in cases where the difference in length was 5cm!
5. Scoliosis= A lifetime of back issues?
Not true! We see so many adults who were abruptly diagnosed with a ‘scoliosis’ after being
asked to bend forwards and touch their toes by the school nurse back in the 1970’s. The difficulty with this is that
the tests for assessing scoliosis have a false positive rate of at least 60%, and the statistical risk of having a scoliosis that requires treatment is only 0.2%. Why are we telling you this? Because once we’re told we have a “condition” it becomes ingrained in us. Part of who we are. So time and time again we see adults who tell us they have a “scoliosis”, and have been plagued by a lifetime of avoiding activities because of their diagnosis, when mild scoliosis (less than 30 degrees deviation) may simply be monitored and treated with exercise.
6. Knees to chest- the ultimate back stretch
Sure, it feels good, lying on the floor pulling your knees into your chest. Depending on your diagnosis, it might even be the right exercise for you, but if you’re one of the many patients I see who doesn’t cope well with forward bending, this exercise isn’t ideal. Why? Because pulling the knees to the chest gives you the perception of relief from your lower back pain (because the stretch receptors in your erector spinae muscles are stimulated) but this type of exercises causes more cumulative damage to the discs, leading to increased pain and stiffness the next day. As practitioners, we know to eliminate these type of exercises and prescribe ones appropriate for your needs- in fact this bespoke rehabilitation plan is one of the main benefits of coming to see a chiropractor.
So where do we go from here?
As you can see, misleading information and advice regarding back pain can lead to us performing the very movements that worsen our back pain in our attempts to get it better. Ensuring you have an accurate diagnosis, treatment plan and rehabilitation strategy is vital to recovery.No treatment plan can be truly successful without incorporating spinal rehabilitation exercises that work to remove the faulty movement patterns that cause back pain problems. We have to work with our clients to ensure that we incorporate exercises that help you build the capacity of the muscles in your back to cope with the tasks you ask of it each day. As you can imagine, each persons’ day is different, and so your treatment plan will be too.
Throughout February we have been posting our top tips to get fit and healthy the best way possible in February. Here’s to committing to your workouts after the initial ‘New Year’ rush! Are you ready for our top tips to conquer ‘Fitness February’!? (More to be added soon!)
Protect Your Neck – Tuck your chin in and put your tongue on the roof of your mouth when you do crunches. It will help align your head properly, which helps reduce neck strain.
Don’t exercise when you’re sick – You’re better taking a day off so your body will use its resources to heal itself, not build muscle and endurance.
If you want to exercise before work but aren’t a morning person, try this trick: For a set period, let’s say 4 weeks, force yourself to get up 15 minutes earlier than normal and go outside for a quick walk. Make it so easy that you don’t even have to change into your workout clothes. As you near the end of the 4 weeks, you’ll have a new habit and will then be able to progress to either longer walks or a run in the morning!
Improve your balance – Stand one-legged on a sofa cushion and move a medicine ball (or heavy phone book) from hand to hand, side to side, and behind your head. Once you’ve mastered the move, try it with your eyes closed. This technique will improve your balance, coordination, and body control, all important athletic attributes.
Run Injury-Free – One week out of every six, cut your weekly training mileage and frequency in half. You’ll give your body a better chance to recover, and you’ll avoid permanent, nagging injuries. Find out more in our Running without pain resource.
Run Hills Faster – When running uphill, keep your head up and your eyes focused on the top of the hill. This opens your airways, making it easier to breathe than if your upper body were hunched forward. Find out more in our Training, Injury prevention and recovery resource.
Loosen Your Hips – Keep your heels on the floor when you squat. If you can’t, your hip flexors are too tight and need to be stretched out! Try this stretch: Hold onto the sides of the squat rack and lower yourself until your thighs are parallel to the ground. Hold this for 30 seconds. Return to a standing position, then repeat five times
Replace Your Shoes (Not Your Knees) – To avoid injuries, write an “expiration date” on your shoes as soon as you buy them. Shoes last about 500 miles, so simply divide 500 by your average weekly mileage to determine how many weeks your shoes are likely to last.
End Back Pain – For every set of abdominal exercises you perform, do a set of lower-back exercises. Focusing only on your abs can lead to poor posture and lower-back pain.
“Slipped discs”- the much-maligned cause of lower back pain. Or are they?
Ah, “slipped discs”. Many of our patients come to see us because they’re worried they’ve got a bulging or slipped disc. To properly explain a disc injury, we need to understand the anatomy of the area and what we’re dealing with. The spine is made up of individual bones called vertebrae. These vertebrae are attached to each other with ligaments which provide additional support and strength. There are also numerous muscles which surround and attach to the spine. In between each vertebra in the spine is a disc which is made up of two parts (rather like a jam doughnut!) There is a tough, rubber-like outer part called the annulus fibrosus, and a softer jelly-like middle part called the nucleus pulposus. These discs sit in between the vertebrae and act as a shock absorber for your spine- a job they ordinarily do very well. Like a doughnut, there’s a certain amount of “squish” to them. This means they can withstand a large degree of force without any issue at all.
A disc protrusion occurs when there is damage to the tough outer layer of the disc. In some cases this allows some of the jelly-like nucleus pulpous into the spinal canal, where the spinal cord passes. This type of issue can put pressure on the whole spinal cord, or just one single nerve root (where a nerve leaves the spinal cord).
Whilst the words bulge or protrusion may seem interchangeable, they do have different meanings.
Disc herniation/protrusion= less than 25% of the disc diameter is involved
Disc bulge= more than 25% of the disc diameter is involved (these are often broad and can involved the whole disc)
Disc extrusion= similar to a disc bulge or herniation but one that extends above or below the level of the disc
Disc sequestration= the material of the disc extrusion passes into the spinal canal and may become separate from the rest of the disc material.
How (and why) do disc injuries occur?
It’s not clear. There is an age factor, as we get older our discs have a lower water content and are therefore more likely to become injured.
Some studies have indicated that repetitive loading and compression of the spine (particularly in forward and backward bending) may have an affect. This was performed on porcine spinal segments (pigs!) This is still worth considering when we see someone in clinic who has a job that involves a lot of manual lifting.
Rotation or twisting may also increase the likelihood of a disc injury. Twisting causes micro-injuries to the annulus fibrosus, leaving the discs more open to injury.
Occupational factors are also important as the risk of lumbar disc injuries are higher among both men and women who have strenuous, physically demanding jobs. People who do a lot of driving may also be at risk. (Sitting puts the spine in a sustained position of slight forward bend which may explain this). Poor posture can also affect spinal flexibility and increase the likelihood of a disc injury.
Smoking also plays a role, as it affects the flexibility of the discs. Lack of regular exercise, a poorly balanced diet and being overweight can also contribute to poor disc health.
So why won’t anyone MRI me?
Good question. Guidelines nowadays state that MRI’s for lower back pain should only be taken when considering referring a patient for spinal fusion surgery. In fact, the use of most imaging modalities (such as x-ray or MRI) are strongly discouraged as they show so many false alarms. We know from numerous studies, that a large number of pain free patients will show disc protrusions on imaging. But they’re pain free! Just because an MRI shows a disc injury doesn’t mean that this is why you’re in pain.
An example of this– In 1989, 67 asymptomatic patients with no pain and no history of back pain were given MRI’s. Clinicians wanted to see if they could predict which of these patients would develop back pain. They followed these patients for 7 years to see if they did develop back pain. At their initial scans, 31% of these asymptomatic, pain-free patients had an “identifiable abnormality” of the disc or spinal canal at this time. (12 patients had normal findings, 5 had herniated discs, 3 had spinal stenosis, and 1 had moderate disc degeneration.) 7 years later, these patients were contacted to see if they had developed back pain, and 31 of them were sent for a repeat MRI. Of those who completed the follow-up assessment, only 21 subjects developed back pain within the 7 year period after the initial examination. At follow-up, 58% of them had no back pain at all, yet the repeat MRI showed more disc protrusion, degeneration and spinal stenosis than the original scans. This study basically scuppered the theory that an abnormality on an MRI was a predictor of developing back pain or sciatica!
That’s not the only study, either. We’ll do the rest quickly!
Fraser et al (1995) 56 patients were MRI’d 10 years after treatment for disc herniation. At the 10 year follow-up, 37% of patients still had the disc protrusion, but there was no relationship between the persistent disc herniation and the degree of patient satisfaction. (“The presence or absence of herniation at 10 years had no significant bearing on a successful outcome.”) So patients had a “successful outcome” from treatment, but still had the disc injury.
Jenson et al (1994) 98 asymptomatic (pain-free) patients were MRI’d, and 64% of participants had abnormal findings on the MRI. 52% had a disc bulge, 27% had a disc protrusion. 1% had a full blown disc extrusion- yet they had no pain.
Do you see what we mean? Here’s a few more!
Boos et al (1995) 46 asymptomatic people who were thought to be “high risk” for disc injury (due to the nature of their work which involved frequent bending, twisting, heavy lifting, contact with vibration or sedentary job roles) were MRI’d. 76% of these people who were pain-free but at high-risk of developing a disc injury were found to have at least one disc herniation yet they had no pain! Not only that but 85% had confirmed disc degeneration at at least one spinal level.
Weishaupt et al (1998) 60 people who had never had back pain before were MRI’d (20 aged 20, 20 aged 30, 20 aged 40). 24% of the group had a ‘disc bulge’, 40% had a confirmed disc protrusion, 18% had disc extrusion.
Masui et al (2005) conducted follow-up studies of 21 patients who were treated conservatively (without surgery) for painful disc injuries. They found that there was progressive disc degeneration in all of these patients, but no relationship between MRI findings and continued pain. The authors concluded “clinical outcome did not depend on the size of herniation or the grade of degeneration.”
What can we tell from these studies?
In any group of people, around 60% of them would have some type of either disc protrusion, bulge, herniation, extrusion or sequestration with or without nerve root compression.
This has all been summed up nicely in a recent study by Brinjikji (2014) “Thirty-three articles reporting imaging findings for 3110 asymptomatic individuals met our study inclusion criteria. The prevalence of disk degeneration in asymptomatic individuals increased from 37% of 20-year-old individuals to 96% of 80-year-old individuals. Disk bulge prevalence increased from 30% of those 20 years of age to 84% of those 80 years of age. Disk protrusion prevalence increased from 29% of those 20 years of age to 43% of those 80 years of age. The prevalence of annular fissure increased from 19% of those 20 years of age to 29% of those 80 years of age.”
Now of course there are cases where we do worry. No practitioner in their right mind would ever ignore a red flag, which indicates underlying pathology. When it comes to MRI’s it’s near impossible to get a completely healthy looking scan out of anyone. It just doesn’t happen, and yet most of these “abnormal findings” on MRI’s are clinical red herrings. They’re as unremarkable as that birthmark on your leg, and yet they can scare people silly.
Can’t I have an MRI just in case?
Surely an MRI “just to rule it out or confirm it” isn’t harmful, right? Wrong! MRI’s and x-rays, particularly those that do come back with some form of abnormality can genuinely scare people. These investigations reinforce the idea that something is wrong, broken, damaged. What we all know to be true is that pain is always worse when you believe you are in danger.
To quote the great Lorimer Mosely:
“Any piece of credible evidence that they are in danger should change their pain … And they are all walking into a hospital department with models like this on the desk: what does your brain say when it sees a disc that’s slipped so far out it’s sitting on it’s own? If you’ve ever seen a disc in a cadaver, you can’t slip the suckers — they’re immobile, you can’t slip a disc — but that’s our language, and it messes with your brain. It cannot not mess with your brain.” Watch his talk here.
Your spine is a fundamentally stable structure. Discs don’t slip in and out for no good reason. Nerves don’t get “trapped and untrapped” and your spine is actually well-equipped to cope with most stresses and strains. Stop worrying- worrying about it serves no function other than to ruin your day!
If you’ve read our “Understanding Pain” blog you’ll know that whilst pain isn’t all in your head, the psychological stuff going on in there does affect your pain, and this is why in our chronic pain patients we do recommend CBT or at least doing some research into understanding pain. How you think and feel about your back affects how much pain you perceive. It’d be fairly silly of us as clinicians to ignore that. This is why it’s so important your chiropractor reassures you during treatment. In addition, we also need to help you understand what’s happening and encouraging you to get back to normal activities.
“You’ve got a slipped disc” seems to be said too often and carelessly by healthcare providers. It’s an easy enough thing to say, it’s often in line with what you think is going on yourself. Now whilst it’s easy to give a diagnosis like that, it’s clinically inaccurate and psychologically damaging. Plus, as you can see from all of the above studies, it’s unlikely to be the real reason you’re experiencing low back pain. We’re much more interested in identifying the actual underlying cause for the pain. This could be inflammation in the spinal structures, restricted joint movement, muscular tension or nerve irritation. Addressing this will get help get you better.
Don’t blame discs- They’re not the problem! Let’s find out the real cause of your back pain instead.
Did you like what you’ve just read? Keen to find out more? Download our bestselling resource “Understanding Pain” to find out how your brain adapts to chronic pain, and what you can do to overcome it!
Prefer to listen instead? Here’s Philippa’s recent talk on slipped discs.
How well do you understand the pain you experience?
Pain is defined as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage”, which is an interesting concept in itself as the definition clearly states that pain can be tangible, or simply mean that the potential for damage is there.
The amount of pain you experience does not relate to the severity of the injury you have sustained- think how painful a paper cut can be even though it is a relatively minor injury! Similarly, we can continue to experience pain long after the original cause has resolved, simply because the body perceives that we are still in danger; this is due to changes in the local tissues.
One common misconception is that pain is produced by injured structures- but we now know that pain, no matter where or how it is felt, is produced by the brain. Before our brain will tell us something hurts, it will first process a vast amount of information before deciding if we need to experience pain. Have you ever cut yourself and not realised until you looked down and saw blood? This is because your brain processed the injury and did not perceive it as a threat to warrant pain signals. Pain relies heavily on context and the brain’s perception of further threat- if you bump into a lamppost, it will hurt, but will it still be painful if you’re about to be run over by a train? Unlikely, because your brain will realise the incoming train is life threatening !
Pain can be both a help, and a hindrance- for example, if we put our hand on a hot stove, the acute pain we experience tells us that we are burning ourselves. However, persistent pain can be very unhelpful as often it does not indicate ongoing damage. This persistent pain is like leaving the volume knob on our radios turned up to maximum- it can block out other senses and become very disruptive in our lives.
When we are left with persistent or chronic pain, it can be hard to believe that there is no ongoing damage, it is because this persistent pain is more to do with our nervous system’s interpretation of the information it is receiving. If you were asked to do the same task all day every day, it wouldn’t take long for you to become very good at it, performing the task quicker and more efficiently each time- the body can do exactly the same. It can become very good at sending pain signals, and can actually adapt so that it sends these signals more frequently. The body can then become so sensitive that it misinterprets normal messages (such as light touch) and responds to them as if they were dangerous. We call this process “sensitization”.
What happens when our nervous system becomes sensitized?
When we perform recurrence activities they become familiar to us, and we become very good at doing them efficiently. Now try to imagine if these activities were painful to perform. If we perform these painful movements for long enough, the brain will associate the connection between those movements and pain, to the point that even preparing, or thinking about a movement can cause pain. This can be very confusing and worrying if we do not understand why this is happening.
Deep, unexplained pain can often cause more worry and anxiety simply because we cannot see what is happening, nor can we sometimes understand why it is happening. As the definition of pain says, it is both a physical AND an emotional experience- the two go hand in hand.
Have you ever noticed your back pain gets worse when you are stressed at work, or not sleeping well? Have you ever noticed your back pain gets better when you’re on holiday, relaxing in the sunshine? There is a vicious cycle that exists between pain and anxiety, which can be hard to break.
What we focus on as practitioners is addressing the factors that have led to us feeling pain. These factors can be our overall physical wellbeing, social environment, health beliefs, mental health, and social environment. We aim to progressively increase your activity and work to restore your confidence in movement as these will all help to reduce your pain levels, and help break that vicious pain cycle and turn it into a positive experience whereby more movement and confidence means less pain.
So how do I help myself?
If we learn to view pain as a motivator to encouraging us to help our bodies, we can start to work with it to get ourselves better.
Exercise. Implementing strategies to encourage more physical activity will help your body release feel-good chemicals (endorphins) which will make us feel better, blood flow to the brain increases and so our ability to function and concentrate improves, muscle strength and endurance will improve. Remember, as you start to become more physically active, you are likely to continue to experience some pain- however, hurt does not equal harm. With practice, and focus, normal movement will return and your pain levels will decrease.
Set yourself realistic goals. As humans we often set ourselves up for failure by setting unattainable targets (New Year’s Resolutions being a prime example), and so when we do fail, we lose the motivation to try again. Set yourself an attainable target, such as being able to walk the children to school and back within three months, or being able to hoover the lounge without sitting down. Competing in your very first triathlon in a months’ time is NOT an achievable target for everyone.
Take charge of your pain. Learn more about it, read around the subject, understand your condition. By increasing your understanding and addressing your thoughts and feelings about pain, you can actually affect your own pain levels by giving yourself more control over your pain. No health professional can take your pain away from you, you must take control. There are a number of resources available to help you learn more:
What is your coping strategy? You might think that the sympathy offered to you by friends and family is helpful, but we actually know that those with a more attentive, concerned spouse/partner will report higher levels of pain.
If you have been prescribed help, this must make sense to you and increase your understanding of your problem. If something does not make sense to you, ask, we are here to help. A good clinician will help you master your situation but you must feed back to them if you do not understand what they say.
Research shows that if you have a good understanding of chronic pain, you can feel more in control, make better decisions in your self-management of pain, and experience less pain as a result. Taking simple steps to increase your understanding of pain, such as reading and understanding this blog post, means you are already making a positive step to addressing and taking charge of your pain.