You get your hair cut. You go for dental checkups. Why not take care of your back health this week?
It’s Chiropractic Awareness Week 8-14th April and we’d like to invite you and your family to benefit from a spinal health check and posture review, where we can offer some advice on how to care for your back. You can also find out how chiropractors can help you move better and feel better.
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.
Chronic shoulder tension. Knots in your upper back. Stiffness, headaches, neck pain. Sounds familiar? Yep- we see chronic shoulder tension a lot in clinic- but allow us to explain why simply treating the shoulder isn’t going to solve the issue.
Firstly, muscles don’t work alone.
Our body moves and functions through a combination of movements in a coordinated group of muscles, ligaments, fascia, tendons and joints. Back pain is our bread-and-butter as chiropractors, and we know from both research and experience that pain in the back doesn’t necessarily mean a problem in the back. That pain could be caused by a problem somewhere completely different- something that often causes a bit of confusion when you come to see us for pain in one area and we end up treating somewhere completely different.
Let us paint you a picture. You work in an office. You’re stuck at a desk all day, sitting on your behind, slouched and worn out by 5PM. Your shoulders are tight and sore, and you can feel the knots building up in your upper traps, giving you a thunderous headache by the end of the day. Now, you know those knots and tense muscles are going to cause problems of their own, so you had an upper back massage two days ago and they should be feeling better… but they’re not. So is the problem the upper traps and shoulders, or is it something else?
Let’s look at the latissimus dorsi.
It’s a muscle that originates from the spinous processes of T7-L5, the iliac crest around the top of the pelvis, the thoracolumbar fascia in the middle of our back, the lower border of the shoulder blade and the lower 3/4 ribs. (Yep, it’s massive!) All those fibres attach to the humerus (the long bone in the top of your arm). Why are we talking about a muscle in the lower back? Surely a muscle in the lower back controls the lower back, right? Wrong. The lat dorsi actually serves to extend, adduct, flex and internally rotate the shoulder, and lends a mere helping fibre or two to extend and laterally flex the spine. (In case you’re interested- it also helps with our lung function and breathing. Safe to say, it’s a pretty important muscle.)
So, back to you sat at your desk.
You’re slouching, your lumbar spine is curved and unsupported, so your latissimus dorsi is stretched beyond the norm and the fibres can’t fire properly. As a result, the muscle can’t complete the role it’s supposed to, the upper trapezius steps in to help and is left to do all the hard work controlling the shoulder itself (Just like that last project your boss asked you and Jane to do together and Jane left it up to you to do all the hard work- thanks Jane….) This leads to imbalance and weakness in both the lats and lower traps not to mention a very grumpy upper trapezius. You’ve tried treating the site of the pain (with that amazing back, neck and shoulder massage) and it feels better for a day or two afterwards but then it comes back.
It’s fairly obvious by now that the problem with your tight and knotty upper traps isn’t caused by your shoulders- it’s something further afield.
So we have to look elsewhere- we look at your lower back and find that your latissimus dorsi is, surprise surprise, not happy with life. Now we’ve found that we also need to look at the Posterior Oblique Sling.* The POS includes the latissimus dorsi, glut med (in the back of the hip) and the thoracolumbar fascia (in the middle of our back.) *NB When we talk about one of the “slings” in the body, we’re talking about a specific group of muscles, fascia and ligaments which all work together to stabilise and mobilise the body.
Guess what we find when we examine you?
Your lat dorsi isn’t firing properly, which is throwing off the stability in the posterior oblique sling. Your lower back is stiff and restricted, and you can’t laterally flex properly- further compounding the problem with the latissimus dorsi (remember us saying it helps with lateral flexion of the lumbar spine?) So you can see how you’re caught in a vicious circle of dysfunction creating more dysfunction, and, in your case, leading to chronically tight shoulders that just never seem to get better!
The above is just an example of a classic case we often see in clinic.
Now, there are approximately 640 muscles in the human body, all intricately involved with the others in a chain of movement, that can have a chain of consequences if something in that chain misbehaves. To state the obvious again- each person we see is an individual, and the way dysfunction comes about is different for each person, as is the way in which the body adapts to that dysfunction.
As chiropractors, our job is to work out what’s going on and why (and then work with you to get it better) and this often involves looking at areas that might be quite far afield from where the actual pain is felt- but as you can see, there’s a reason for that.
So where to begin? How can you improve your posture and reduce pain and problems? We’d suggest starting with some simple exercises, and downloading your copy of “Understanding Pain” which will help you get to grips with chronic pain, what’s going on in your body and how you can take back control!
Alternatively, and perhaps best- is to seek professional help and get a diagnosis and treatment plan put in place. You can get started by booking your appointment today.
Thank you to The Run Company for letting us take over your shop for those evenings!
There are some big races in every runner’s diary at this time of year, including the largest local marathon taking place in June and international races coming up in the Autumn. Nothing’s more disappointing than picking up an injury just a few days before the big event, so in this workshop, we took our guests through the top prevention steps everyone needs to know to prevent injury, helping you spend more time on the road and less in rehab.
We covered everything from overtraining to optimum performance tips as well as advice on the all-important recovery period, and an opportunity to speak to Philippa, Acorn Healths principle Chiropractor, one-on-one after the event for any specific questions or advice.
We had an Ultra-marathoner and a Tough Mudder runner who had specific questions on nutrition and keeping up their energy levels. We also talked to a few ladies who are looking to improve their stride to reduce expelling unnecessary energy, and a 10K runner interested in injury prevention. We also had a lady interested in increasing her walking to running without causing serious injury and a gentleman looking for information on running winter marathons.
Our events are never a dull affair, and all are encouraged to get involved and ask questions throughout the talk. We left the first event thinking about stocking up on jaffa cakes and jelly beans and the last one thinking about taking a nap! If you are interested in coming to one of our events please subscribe to Facebook events here or sign up to our newsletters here.
Book in for your pre-race MOT appointment here so we can get those backs mobilised, ribs moving freely to increase your lung expansion and thus your muscle moment and improve your hip flexion and extension for a better stride.
Your body is an intricate machine and just like any machine, things can go wrong from time to time. If you are in pain, it’s your body’s way of telling you that something isn’t right. Listen to it.
“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.
Living and working in Emsworth and Langstone, you’ll know that sailing is an inherent part of our community here (so much so, we’ve included some photos taken by Philippa of our lovely harbour!) As such, it’s not uncommon for us to be treating professional or recreational sailors in clinic, and whether you compete professionally or just enjoy a turn about the Solent, sailing poses as much a risk of injury as with any sport.Sailors often compete in extremely difficult conditions, battling high winds and rough seas, and as such the risk of injury during sailing is 8.6 per 1000 hours sailing when training, and 2.2/1000 otherwise. In a study on the 2003 America’s Cup, researchers found that the upper limb was the most commonly injured body segment (40%), followed by the spine and neck (30%), and the most common injuries were joint/ligament sprains (27%) and tendinopathies (20%). (1)
Who is at risk of injury?
Mastmen are at greatest risk of acute injuries, helmsmen most commonly injury the upper-limb through steering, whilst grinders and bowmen are at the greatest risk of injury from repetitive strains. High repetition activities such as hiking, pumping, grinding and sterring are major causes of overuse injury, even in the most experienced of sailors. Windsurfers are also frequently admitted to hospital suffering from chronic lower back injuries as a result of “pumping” the sail.
It’s not just the professionals who are at risk of injury, as novice and recreational sailors commonly encounter acute injuries such as contusions or abrasions after colliding with the boom or other equipment whilst performing manoeuvres. (1) Not only that, but there are other perils to consider: tripping over ropes, winches and cleats; being swept overboard or falling down open hatches!
How and why do sailing injuries occur?
[clickToTweet tweet=”What are the main contributors to #sailing #injuries? Find out here! #Chiropractic” quote=”The main contributors to sailing injuries are: Heavy weather (23%), tacking (17%), jibing (13%), sail change (12%) and alcohol (7%)”]
Injuries may result from a lack of general fitness, overuse, overtraining, or macrotraumatic accidents.
Lack of warming up, stretching, and cooling down may also increase the risk of injury.
Muscles are placed at high risk when performing explosive, powerful moves, such as those frequently required when sailing.
Shoulder and arm injuries are common through constant handling of the mainsheet, and the sudden, strong movements in hiking may lead to back and knee problems. (Remember Sir Ben Ainslie’s back injury? This was caused by repetitive, high strain hiking out!)
Inadequate leg strength and poor hiking technique are thought to predispose the knee to injury.
Boats can be difficult to navigate around and result in crew members having to adopt awkward positions, often resulting in rotating, hyperextending, locking, or twisting of joints.
Postural problems are common in the majority of the population, and these inherent issues can lend themselves to musculoskeletal problems.
Poor fitness training may exacerbate common muscular imbalances associated with changing forces on opposing muscle groups while sailing.
If ignored, it is easy for these issues to progress into a chronic problem, the possible severity of which could impact on your participation and enjoyment in the sport.
So what can be done about it? Five simple steps to avoiding sailing injuries!
A robust exercise regime is crucial, which should focus on all aspects of physical fitness in order to ensure that your body can cope with the demands of sailing.
– Cardiovascular training
– Strength training (Competitive sailors should undergo regular health screening with specific strengthening of high-risk muscle groups, synergists and stabilizers. )
– Flexibility training
– Core stability training
– For more advice on bespoke rehabilitation plans, please email us at email@example.com or visit our Langstone clinic.
Research has shown that aerobic training and fitness is directly related to an improved reaction speed to wind shifts, as well as enhanced endurance, decision making, and concentration, particularly in the later stages of races. Mental and physical recovery is faster for those who are physically fit. Suggested types of aerobic exercise that are most appropriate for sailors are rowing, cycling, swimming, stair climbing, or running.(3)/li>
Regular checkups can help ensure joint movement and function is maintained, as well as provide an opportunity for assessment of joint strength and function. Not only will this help reduce the risk of developing injuries, but it can also speed up recovery should you become injured.
Technical skill and expertise is important– if your technique needs improvement, seek out advice and informed coaching to help minimise the risk of developing an injury as a result of poor technique.
Taking frequent breaks and changing positions during long periods of sailing. This will help prevent postural stresses and strains from occurring and is a healthy spinal habit we all should follow.
Whilst we have focused on musculoskeletal injuries, there are a number of other safety measures to take into consideration. Above all, always wear a life jacket when sailing. In the UK, there were 35 sailing or water-sport related deaths at sea in 2014 alone. Safety at sea should always be taken seriously.
1. Neville, V., Folland, J.P. (2009) The epidemiology and aetiology of injuries in sailing. Sports Medicine. 39(2) 129-145.
2. Nathanson, Mello, Baird “Sailing Injuries and Illness – Results of an Internet-based survey” Wild Env Med 2010
3. Allen, J.B., De Jong, M.R. (2006) Sailing and sports medicine: A literature review. British Journal of Sports Medicine. 40(7) 587-593.