My Big 3 On Back Pain

In Canada, 1 in 5 individuals struggle with chronic lower back pain and, tragically, this condition is mistreated on a worldwide scale.

This being said, one of the most important tools we have in addressing this crisis is not in the techniques and machines at our disposal; rather, it's the knowledge and education on the nature of back pain itself. Here is a list of need-to-knows for your pain.

Imaging Often Gives Inaccurate Pain Diagnoses

A lot of people are sent straight to the x-ray lab upon seeing the doctor about their back pain. Unfortunately, the results of imaging often do not reflect the actual nature of their problem and can sometimes even make the problem worse.

Asymptomatic individuals have a high rate of having abnormal findings on their scans. This suggests that the actual cause of pain isn't necessarily the physical structure of the spine, shifting our need to focus on something other than just decompression and surgeries. Which leads us to...

Your Nervous System Is The Likely Culprit

Tissue heals. Muscle repairs. Bones regrow. But pain does not always go away, even after the body itself has otherwise bounced back.

The nervous system, itself, can runaway from us, releasing and propagating nerve signals once the initial injury or stimulus triggers them. And no, this does not mean that the pain is in your head; it means that the nervous system, while being integrated with the body's other systems, is still it's own entity that must be treated as well.

Flexibility Probably Isn't The Key

A lot of people assume that their persistent back pain is caused by "just being tight" and attempt to resolve the problem through an aggressive stretching routine. True, while yoga is suggested to offer some benefits in relieving back pain, the actual relationship between lack of flexibility and pain is comparable to that of the x-ray findings.

This is especially good to know for when it comes to those who attempt to fix their pain through aggressive self-massage. Sometimes, a lack of flexibility is there for a reason, and releasing a muscle too much could actually result in more pain.

This might tell us that the yoga benefits are more to do with the strength and postural control than anything regarding muscle lengthening, giving us a place to productively start looking for solutions.

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Guilt and Recovery

How many of you have been to a therapist's office in the past and felt guilty during the follow-up appointment? Maybe you didn't do your home exercises or pushed it too hard before you were ready. Maybe you're simply not feeling better and think that there was more that you could have done.

The less mindful therapists out there may look at a client who didn't quite perform up to par and simply utilize that shame as a lesson-learned to push that client into further adherence. How far does this shame help an individual's motivation, though?

Quite a ways back, I wrote about health-shaming with the assistance of a sports behavioural consultant. With the example of guilt in relation to diet, it was shown that higher levels of guilt were associated with a poor perception of control and decreased rate of success when it came to changing a behaviour.

In short, the more guilty a person feels about poor progress when trying to change, whether it's with diet, fitness, or pain-control, the lower rate of success to make that change!

From a personal standpoint, I've experienced this with clients who simply "fall off the wagon" and relapse in their pain and health. Regardless of whether it was their own doing (ie: poor exercise adherence) or not (time barriers or accidents), this sense of guilt has resulted in a lack of drive to continue forward.

As far as I'm concerned, if a client feels guilty, then the onus is on myself just as much as it is on them. It's my job, as the therapist, to create and enforce realistic expectations with a client's habits that they are happy with as well as to help them plan for any contingencies or relapses. Clients of any type of medical practitioners must not feel like they aren't "being good" and can't face the person who is working to help them. If any professional is making you feel bad about your performance, you may be developing a toxic relationship.

So to any individuals out there who are in pain, please don't feel guilty.

To the clinicians, stop making your clients feel guilty!

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The Sixth Sense You Need For Injury Prevention

In broad, obvious terms, we have five senses. Touch, taste, sight, smell, and hearing. In reality, however, the body actually has many more sensory systems than that. Thermoreceptors in the body detect temperature; chemoreceptors detect chemical changes (such as what your immune system requires); equilibrium from your inner ear handily lets you know if you happen to upside-down or not.

And then there's proprioception, which happens to be one of the most important senses that our bodies have in order to move, function, and avoid pain and injury.

Proprioception is the sense of where a body part is in space. For instance, if you close your eyes and raise your arm into the air, you will, no matter what, be aware that you arm is above your head.

Where is it? WHERE IS IT?

Those proprioceptive sensations can be much more subtle than that as well, though. Take, for example, single-leg standing on an unstable surface. It's your body's ability to sense minor changes in position and weight shift that contribute to your ability balance. That proprioception that you have for the joints in your leg provide the feedback that your brain needs to coordinate the muscles in this case.

With that in mind, it should be easy to understand how a lack of well-trained proprioception can result in a higher risk of injury. Lacking proprio in a joint certainly affects its overall stability, increasing the chance of tissue failure when the body can't properly adjust for a stimulus.

From observation and speculation in the research, there's also a link between a lack of proprioception and chronic pain in absence of true tissue damage. Lower back pain patients, for example, are demonstrated to have this sense impaired basically across the board! It may be that the body's inability to accurately reposition itself as needed could be resulting in increase muscle-guarding activity and heightened pain sensitivity as a protective response.

This being said, proprio is a vital system to retrain when rehabbing clients. It's not as easy as simply strengthening some muscles and increasing flexibility in others, as the body still won't be receptive to letting go of it's protective responses if it can't effectively sense those changes in joint position. In fact, I've had incredibly strong clients with no significant weaknesses remain plateaued in their recovery simply due to this fact! Given that proprioception can be lost as a result of injury, surgery, and even growth spurts, being mindful of this domain is one of the most crucial aspects of an effective recovery program.

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What We Know About Tendinitis (May Surprise You)

Achilles tendinitis, tennis elbow, rotator cuff tendinitis, these tendon conditions are all common causes of pain that I see in my practice with much frequency.

What many of us usually understand about tendinitis is that it's a condition involving inflammation of a tendon resulting from overuse and repetitive trauma to the structure. Responses to the diagnosis are typically to rest, apply ice for the inflammation, and then pop an Advil to further get that anti-inflammatory affect.

However, what we now know about "tendinitis" may surprise you. Rather than being an inflammatory condition (as the "-itis" suggests), we're finding the condition to be a structural one with changes to the tendon fibers occurring at the cellular level. Often, a complete absence of inflammation is observed, resulting in the research shifting to the terms, "tendinosis" or "tendinopathy", instead.

We can simplify the explanation by visualizing normal tendons as having neat, aligned fibers that are all closely packed together and running in the same direction. Normally, we think of tendinitis as this structure remaining, but inflammation and swelling simply occurring in the area due to applied stress. We know this as incorrect, though.

Instead, tendinosis involves that neat alignment of the fibers as becoming disrupted. In healthy tendons, there is regular fiber-growth activity replacing old fibers with healthy new ones in the similar fashion. In unhealthy cases, new growth of fibers is occuring in overtime (which is the reason for thickening of affected tendons) as well as growing irregularly and nonuniform, affecting the structure's functional ability and resulting in pain.

• https://doi.org/10.3810/psm.2000.05.890

It was once thought that tendinopathies occurred in stages, with the inflammation occurring first and then the structural changes of tendinosis resulting if the condition progressed. It seems like true inflammation is rare in the first place, though.

• https://doi.org/10.3810/psm.2000.05.890

The implications of this reality don't impact the prognosis of the condition; outcomes are still very positive with proper treatment. It does affect the way that we treat and the time that recovery may require. Those structural changes definitely indicate increased time for reversal than simply decreasing inflammation would. As well, they indicate how much more importantly mechanics are loading must be considered for future prevention. (Pro-tip, tendons love eccentric training.)

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