Managing Back Pain - Take an Active Approach

Back pain – GP, Specialist, physio, chiro, osteo, your personal trainer, thai massage, sports massage, acupuncture, pilates, yoga – so many options for treatment it is hard to know who to see to set you on the path to recovery. It is a dilemma for a huge number of people, it is estimated that 70 – 90% of the population will experience low back pain at some point in their life. In the 2011/12 Census, 3 million Australians (13.6% of the population) had back pain. For some it may last a matter of days, even hours but for others it can affect them for much longer. Whether it is back pain from performing a lift, moving awkwardly, poor posture or if there's no real reason for it at all, you want to make sure you understand what is going on and the best way to manage it.  

When I see a patient come in with back pain I always try to identify a source and the structures involved in the injury. If there is not a specific 'injured' site in the back – and this is often the case with people presenting with back pain – then I at least want to identify the locations of pain. By coming up with this 'diagnosis', it is then possible to understand what movements, activities, postures, or other areas of the body may be contributing to the pain. Having done this the injury can be explained to the patient, as can the contributing factors and the treatment approach. Education about your back pain is very important, it helps put you back in control and gives you the confidence to move on with your recovery.  

Once a better understanding of the injury has been established what is the best way to treat back pain? It is now widely accepted that the most important thing to do is stay as active as possible – keep moving and return to work as soon as possible. If serious pain is significantly inhibiting your ability to move then your GP is the first port of call. They will assess your injury, can prescribe you with suitable medications to help settle your symptoms and can guide you as to future treatment. 

The treatment you choose should take what I call an 'active' approach to managing your low back pain. As previously mentioned I will try to identify the contributors to the condition and discuss these with the patient. From this a treatment plan will be devised with a key feature being specific movement exercises to help restore normal movement and reduce pain – this fits in with the number one rule of managing back pain – Keep Moving. In addition to this, soft-tissue techniques can be used. This can include a combination of massage, soft-tissue release or mobilisations for the back and surrounding areas. The idea of these techniques is to help reduce pain, take load off the injured area and improve range of motion. It is unlikely that soft-tissue therapy on its own – without education about the injury or advice regarding movement – will result in effective management of the injury. 

Other things no longer recommended for the management of back pain include X-rays or other scans to diagnose the injury – unless requested by a Specialist or if a serious condition is suspected. Belts and braces are ineffective (except in the case of pregnancy where a belt may help reduce SIJ pain). Traction is no longer recommended, nor acupuncture or electrotherapies such as ultrasound, TENS (nerve stimulation) or interferential therapy. There is also limited evidence for surgical and injection therapies at the moment and these should only be considered with your managing GP and Specialist if the above conservative treatment approach has failed.  

Research, my own experience and that of many others suggests an 'Active' approach to the management of your back pain is most effective. Something to consider when deciding on the treatment approach you take for your back pain. 

Stuart McKay
APA Physiotherapist 

*The advice in this article is in line with the NICE (National Institute for Health and Care Excellence) Guidelines published 30 November 2016; Low back pain and sciatica in over 16s.

Physio for Runners

Runners require careful and well structured management when dealing with an injury. It is challenging and requires you to think outside the box a little as a Physio. Identifying an injury in a runner, providing some treatment, maybe some exercises and advising them to rest as it settles isn't going to cut it for several reasons – one of the main ones is runners want to run – and if they're not running it's not only conditioning but mood, health and even sleep that can suffer. More than this, it is unlikely that the problem has been solved. If an injury has resulted from running (and not an unlucky event like rolling your ankle in a pot-hole) then unless the issue with an individual's running – technique, training errors, conditioning etc. – is corrected then a runner will most likely continue to get injured. Having increased my own running the past two years and coming across some issues leading in to a half-marathon or City 2 Surf, not running was an absolute last resort. Training modification and management of the injury allowed me to continue preparing for and complete the events. 

There are many potential sites of injury in runners. Knee injuries account for approximately 50% of all running injuries, with female runners more likely to experience knee problems. Males have higher rates of achilles and calf injuries. Many runners avoid seeking help until the injury progresses to a point where it really affects their running. I always advise runners to let me know early when an issue starts to present as it is much easier to deal with in this early stage. Certain injuries that can develop over periods of time, such a stress fractures, will unfortunately leave you with no other option than to rest while the injury heals. When seeking treatment it is important your therapist understands your running injury and the potential contributors. Is it over-striding?, is your knee dropping in on contact with the ground and why is that happening?, is your training program an issue?, is a previous injury still causing trouble? – the list could go on forever. A thorough discussion between therapist and runner is an important first step so your physio can get to know you, your running, previous injury history and goals.  

Having gained these important insights you should then be taken through a detailed clinical assessment of the injured site and also any area of the body that could be contributing to the injury. This will help formulate a diagnosis and management plan for the injury. However, in many cases this assessment needs to go one step further and look at the runner actually running. It is impossible to understand how a runner runs unless you see them do it. Running is a skill and to improve skills you need to practice them. A runner needs to practice their skill, much like a golfer needs to practice their golf swing and a netballer needs to practice catching, passing and shooting. Unless a runner knows what aspects of their skill they need to be practicing they will not improve. Having seen an injured runner run, the physio can then prescribe cues or drills to help not only settle the injury but make the runner a better runner. 

Treatment will often be multi-factorial for runners. Hands-on techniques, taping, supports and footwear may be implemented to help reduce pain and keep the runner training. It is important while recovering from injury that suitable training volumes are prescribed. Both the runner and Physio need to have a say in this to ensure that both the management of the injury and requirements for any upcoming events are considered. Important aspects of managing running injuries are careful monitoring and reassessment of both the injury and any individual factors you are working on, progressively increasing running loads and allowing adequate periods of recovery. 

My goal as a physio when working with runners is to not only help them recover from the injury with minimal impact on their running but to use the period as an opportunity for them to become a better runner than they were pre-injury. If I can achieve this then not only have we dealt with the current injury, we've reduced the chance of future injury and improved running performance. 

Stuart McKay 
APA Physiotherapist, Owner Total Physiotherapy, working towards first Marathon January 2018 (with two Half-Marathons this year along the way.) 

Pregnancy and Early Parenthood Pains

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My son Caelen is just over 16 months and is the most amazing gift my wife and I could have ever imagined. It has been so rewarding being a part of his development – from pregnancy, the short time he was a newborn (I never realised how short a time your baby is actually a new-born!) and to now, a wildly energetic, curious and cheeky 16 month old boy. While fascinated with his development, my wife and I have also become very familiar with the tired, aching bodies that come with having a baby. As a Physio it has been an invaluable learning experience seeing first hand what happens to a woman's body during and after pregnancy and the demands on your body of caring for a baby.  

There are two big changes to a woman's body during pregnancy that can have profound effects on how their body feels. The first is an increase in the hormone Relaxin – this causes the ligaments supporting the joints in the body to relax, allowing the baby to pass through the pelvis during birth. It's important to note that it is not just the ligaments in the pelvis that relax, it's all ligaments in the body. There are ligaments supporting every joint, this includes the spine, shoulders, elbows, wrist, knees and ankles. As a result these joints are more mobile and will be affected differently by the loads placed on them.  

The other change is a baby growing in your belly, gradually getting bigger and heavier as pregnancy progresses. A growing belly changes your centre of gravity, the curvature of the spine changes to cater for this as does the parts of your body that are getting loaded. In a sport setting, an athlete is more likely to get injured when there is a change to the loads they are exposing their body to. It is no wonder that women experience back, hip and other joint pains during pregnancy with the way their loads are changing. The good news is that although you are sore, generally no significant long-term injury results. However, if you are concerned by the pain and worried you may have a more serious injury discuss this with your GP, mid-wife or obstetrician.  

How should you manage this pain – or is it just something you have to put up with? Not every woman will experience discomfort at the same levels or at the same locations. It is possible to attain some relief and try to limit the amount of pain experienced. From listening to mums and mums-to-be and my experiences as a Physio there is a lot of variability in what works and how much relief each individual receives. Again, your GP, mid-wife or obstetrician can provide you some advice on what might work for you. My tips for managing and reducing pain during pregnancy are: 

• Keep muscles supporting your joints strong to counter the loss of stability provided by your ligaments. Important areas are the core and gluteal musculature, and muscles supporting the shoulders, knees and ankles. You may choose to continue gym training during pregnancy (at the appropriate levels), perform Pilates classes or a Physio can provide you with exercises you can perform at home or in a gym-setting.  

• Massage and gentle soft-tissue release can help reduce pain and help manage the consequences of the altered loading that has occurred. It is to be expected that certain muscles become over-loaded and tight as the way your body carries load changes. I try to identify and target these areas when treating pregnant women and often there is an immediate improvement.  

• As joints are relaxing it is unlikely that joint mobilisation is required or would be beneficial. Occassionally I have used mobilisations when I have thought a particular joint may be a little more overloaded than others. Even then it would only require a small amount of mobilisation and would be most likely used for the upper back or neck regions. Considering what is happening to the body strengthening and massage makes more sense to me. 

• Have some self-management tools available – the ones I believe to be most useful during pregnancy are hot and cold packs, massage balls, foam rollers and natural pain relieving creams. And treat yourself to some relaxation time - find how Total Physiotherapy and Yummy Mummy Day Spa can help with this at the end of the article! 

Stuart with Caelen - demonstrating some pretty poor holding posture!

Following the arrival of your new baby there is a flood of feel-good hormones, your body gradually returns to normal and you have this amazing little person in your life. It is not long until you have forgotten the pains of pregnancy. However, as my wife and I are still discovering, a young one puts a whole lot of new strains on your body. From spending regular periods feeding (and many babies prefer to feed from one side as we discovered), continuously holding/carrying/lifting your child, bending over your child as they get to sleep and long periods pushing a pram (not an exhaustive list) your body is still copping it! Shoulder, wrist, lower back or neck pains are the most common I see as a Physio and all of which both my wife and I have experienced over the past 16 months. 

My advice, and I say this knowing that it is impossible to diligently follow this while dealing with the demands and time constraints of having a baby, is: 

• Don't let soreness build up for too long - If you can get on to things earlier I find it is easier to settle down and the pain does not become as debilitating.

• Resume some of the core and gluteal strengthening exercises from pregnancy once your doctor says it is safe for you to do so. 

• Try to share the load between both sides of your body when carrying and feeding as much as possible. Favouring a side of your body is one of the most common reasons for shoulder, neck and upper back pain in new parents.     

• Gradually resume exercise in a structured way to avoid over-loading your body with an activity it is not used to – keeping the mind what it has just been through during pregnancy. It takes time for your body to adapt to what you are exposing it to so don't try to do too much too soon. If you are unsure of what you should be doing a Physio can help get you on track. 

• Ensure you pram is set-up so you can walk upright and comfortably. Avoid being bent over or slumped when pushing the pram.  

• The same self-management tools above are again very useful – if you can find the time to use them!
  
  I hope you enjoy the experience as much as my wife and I have. Embrace the changes to your body and the amazing new member of your family. Hopefully the tips above can provide you with some relief and if required Physiotherapy can provide some additional relief both during and after pregnancy.   

The above relates to my experiences with normal pregnancy-related pains and conditions. Unusual or severe pains should be discussed with the medical professional managing your pregnancy.  

Stuart McKay 
APA Physiotherapist, Owner Total Physiotherapy 
Writing this as both a proud dad and Physio 

Total Physiotherapy is a new Physio Clinic located on Clovelly Road Coogee. Thanks to the kindness of Yummy Mummy Pregnancy Day Spa also on Clovelly Road, for the month of February we are able to offer the first ten mums-to-be or new mums with a child under 12 months who come in for Physiotherapy a $50 Gift Voucher to use at Yummy Mummy Day Spa.