When Biomechanics DOESN'T Matter

Greg Lehman has been a pioneer in helping us to understand pain and biomechanics and finding out when they matter.

He is a advocate for “Movement Optimism” - an approach that helps you build confidence in your body and avoid the common trap (fueled by well meaning health care professionals) of getting stuck in sometimes irrelevant biomechanical narratives that create fear and entanglement in the body.

I would encourage you to watch at least the first five minutes as he pulls apart the most common things you might hear coming from your health care professionals mouth.

“What I often say is, it’s not the pain science or neuroscience that challenges these biomechanical ideas, it’s the biomechanics itself. And if you know the biomechanics well, you can really see the holes in the common arguments.”

I hope you enjoy this eye opening lecture at the San Diego Pain Summit (click on image below to watch on youtube).

Is there a perfect posture?

“Our bodies love to relax” - Professor Peter O’Sullivan

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A really interesting conversation where the topic of ‘good’ posture while sitting is discussed.

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(Important) take home message

Don’t let anyone tell you there is a thing such as a ‘perfect’ posture.

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Regular change of position (including sitting back and relaxing in your chair) is an important part of having a healthy spine Listen to your body for its cue that it’s time to move.

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If you’ve had persistent back pain this podcast episode is absolute must!

5 Things Everyone With A Disc Issue Needs To Know

The story:

You’re at home and reach down to pick something up and feel a twinge.

Ouch!

But you don’t think much of it.

Until the next morning when you are unable to get out of bed because of severe pain and muscle spasms.

You’ve never felt anything quite like it - even sitting on the toilet is just about impossible.

You ring your doctor and they order an MRI - you somehow you manage to stumble into the radiology centre (lying down for the scan isn’t all that much fun).

The next day you get the results - and it shows a disc in your back has been injured.

You jump on Google and are suddenly confronted with all sorts of pictures showing discs pushing on nerves. Every website you read says that you may need surgery and you should be avoiding heavy lifting, bending and twisting.

Sound familiar?

When you have been diagnosed with a disc issue, you have two problems to deal with:

1. The physical side of the pain that can be overwhelming in the early stages and

2. The mental side, that can be equally as bad. It can very hard to think clearly when your life comes to a complete halt..(who knew back pain could stop you in your tracks so suddenly and cruelly?!)

All sorts of things can go through your head when you are lying in bed, unable to move due to pain.

That you might develop chronic pain. That you might need surgery. That you can’t go through daily life with the same care-free attitude about how you move your body as before. That life as you know it is over and you will be living in fear of recurrence.

But there are some problems with the above scenario.

Some assumptions and beliefs that need some clarifying.

A lot of clarifying.

Be careful who you take your advice from.

There are a lot of unhelpful beliefs out there and you need to avoid catching a 'thought-virus’ that can derail your recovery and unknowingly put you on a path of ongoing pain and dysfunction.

When you have injured your back, it’s amazing how all of a sudden you start receiving all sorts of (unsolicited) advice from every Tom, Dick and Harry on the street.

Everyone has their approach that works for them.

But because there is so much conflicting advice, the uncertainly can make you feel even more confused and scared…what do I do? and who do I see to help?

Recently on a facebook post, a local Adelaide media identify asked, “How do I fix my disc?”

There were around 1,300 comments and I counted at least 50 different types of treatment.

The main thing to ask yourself when hearing advice is,

• Are they using an evidence-based science approach?

If you stop and really think about this, unfortunately many well meaning people (including health care professionals) are simply giving out terribly outdated advice that creates a huge amount of unnecessary fear in people with disc issues.

This blog post is an attempt to clarify some unhelpful beliefs about disc related back pain.

There are 5 things everyone with a disc issue needs to know:

• Scans are often misleading (most people have some disc bulging but have no pain)

• Disc issues generally have a favourable outcome (and like a good wine improve with age)

• The bigger the bulge, the better

• Slumping might actually help you recover faster

• Running is very beneficial for the disc

Essentially discs are one of the most stable and resilient structures in our body.

As always the following information is general and please use in conjunction with your trusted health care professional.

If you have any questions or concerns, please reach out to dan@kinfolkwellness.com.au

Let’s explore each of these statements a little more closely…

1. Scans can be misleading…you can have a disc problem and not even know about it

It must be understood that in the normal pain-free population, there is a high prevalence of abnormal findings on MRI scans (see table below).

Brinjikji et al 2014

This systematic review by Brinjiki and colleagues in 2014 studied closely the MRI’s of asymptomatic people i.e. they had NO current back pain (or any history of back symptoms).

They found that all the people in the study showed some level of disc problems.

For example, 30% of all 20 year olds had a disc bulge and no pain.

This percentage increased with age, with over 60% of 50 year olds having a disc bulge, (and these are people who had no symptoms whatsoever).

This indicates that many of these features—particularly when found incidentally — should not be considered pathological and instead be regarded as normal age-related changes.

This makes it difficult sometimes to find what it truly driving the pain experience.

Many doctors and health care professionals (knowingly or unknowingly) contribute to a heightened pain state and increase risk of catastrophization by doing a poor job of communicating scan results.

Once a fear has been created, adrenaline can surge continually through the body, creating anxiety and fear of movement.

Having an experienced clinician explain your scan findings is an absolutely critical part of your recovery.

Evidence shows that rushing too quickly into an MRI imaging for a back strain results in a poorer prognosis, (with an increased chance of surgery).

After an injury or episode of pain, the body will heal (often over 2-3 month period).

But sometimes the pain can persist because the person feels frightened and intimidated by the diagnosis and there is subsequent ongoing protective muscle spasm (see below).

Some of the muscles that can tighten up after a disc injury and stay locked up, causing ongoing tightness and pain

2. Disc issues generally improve as you age 

Although they can be extremely painful in the initial phase, the natural history of disc issues is favourable and the majority of disc prolapses resolve with time.

Many people assume because they have had a few bad episodes of back pain that they will continue to deteriorate over time. Some people even fear they will end up in a wheelchair.

If you have had these thoughts, I would like to tell you…after 25 years of studying/working as a Physiotherapist, I have never once seen someone’s back pain progress to the point of requiring a wheelchair to get around.

Interestingly, studies (such as above) have shown that as you age, the degree of degeneration in the discs increases when scanned, but that does not correlate with pain, disability or clinical symptoms, which tend to reduce with age.

After the age of 40, your discs actually start to stiffen up and become more stable.

This stability leads to less chance of the disc causing ongoing pain.

So the take home message is once you have had a disc issue you may always have changes on scans. They can be thought of as ‘wrinkles on the inside’ - a normal part of ageing and nothing at all to be concerned about.

3. The bigger the bulge, the better

Some studies indicate that about 85% of lumbar and 90% cervical acute disc herniation will get better in an average of 6 weeks, (but sometimes take up to 3 months for symptoms to settle).

In 2014, Chiu and colleagues conducted a systematic review to determine the probability of a spontaneous disc regression.

The aim of the systematic review was to investigate the probability of disc herniation regression and complete resolution.

The different types of disc issues and severity can be seen in the picture below.

The study showed the probability of a spontaneous regression was:

• 96% for disc sequestrations

• 70% for disc extrusions

• 41% for focal protrusions

• 13% for disc bulges

Essentially, the study offers some very encouraging statistics to tell us that the larger or more severe disc herniations often have a higher chance of spontaneous recovery.

Lumbar disc herniation can regress or disappear spontaneously without surgical intervention.

4. Slumping might actually be good for you

A study done by Pape (2018) showed slouched sitting can rehydrate the lumbar discs and essentially ease the pressure off the discs.

This study showed slumped postures can provide a valuable alternative to upright sitting and “may be recommended for recovering spinal height in the working environment following periods of loading”.

A simple way to think about this is if you were to clench your fist as hard as you can for 60 seconds.

Pretty soon the muscles in your arm start to fatigue and eventually, if you held it for long enough, you’d start to feel some pain from the constant contraction.

Exactly the same thing can happen with the muscles in your spine.

After you’ve had an episode of back pain, you may start to worry about your back, and a well meaning health care professional has told you to “be really be careful with your posture and never slump!”.

Sometimes people can take this literally, always trying to sit up straight and never giving the muscles in the spine a chance to actually relax.

This can lead to the ongoing muscle tightness and tension that we mentioned earlier.

With back pain, there is no perfect position.

You don’t have to sit up straight forever - in fact doing this trying to protect your back may overload the muscles and give you more pain.

The people who don’t get pain and the ones who explore a wide variety of movement and change positions frequently. “You’re best posture is your next posture”.

5. Running significantly benefits the human intervertebral discs

A study recently that showed people who run have stronger and more resilient discs than those that don’t run.

The study showed that long distance runners and joggers had better hydration and glycosaminoglycan levels than non-athletic individuals.

“We expect that tissues will adapt to loads placed upon them,” says lead author Daniel Belavy (Burwood, Australia).

Just like your muscles and bones need stress to grow stronger, your discs also respond and adapt in the same way.

This is great news if you are a runner, as previously it was thought that the impact of running was potentially aggravating to the discs.

Now we know that runners have healthier discs, if you are considering getting back into running I would encourage you to work closely with a Physiotherapist who can help guide you back safely.

Interestingly this study showed a long distance runners using a walk / run pattern seemed to be the best for the disc, as opposed to just walking or always running fast.

This suggest that knowing your ‘easy’ running pace and sticking to it during your recovery phase may be an important part of keeping your spine healthy.

If you would like to find out your easy pace, based on your current fitness levels, please use our free online running calculator.

To be very clear…

Disc issues can be extremely painful and limiting in the first days/weeks and you need to take care of yourself by visiting a Physiotherapist who you know and trust.

Realistically, disc issues can take some time to fully settle down - sometimes up to 3 months.

Disc issues CAN be serious 1-2% of the time.

It will really only start to cause you grief if it starts to contact and compress the nerve root.

If it gets to this point, you may have pins and needles, numbness, weakness of the area supplied by the nerve that is affected.

Some of the signs you may need to consult with a doctor include:

• constant numbness / pain in the leg

• extreme constant pain and not able to get any sleep at all

• bladder or bowel incontinence

But that leaves 98% of disc issues that can be well managed with a personalised Physiotherapy program.

Some people are more susceptible to disc problems than others.

Risk factors include:

• obesity

• lack of fitness

• lack of regular exercise

• cigarette smoking

• history of anxiety or depression

How Physio can help

We are experts in treating people with disc pain and can help you in two main ways:

• designing an exercise program designed to improve strength, flexibility and fitness

• provide short-term relief with massage, spinal mobilisation or manual therapy to reduce pain and get you moving well again

If you would like to find out more information or start your healing journey right away, please use our easy online booking system to find a time that suits you.

Dan O'Grady is a results driven qualified Physiotherapist and member of the Australian Physiotherapy Association.  Dan has a special interest in treating lower back pain.  He has been working in private practice for 15 years. He is passionate about helping people to move better, feel better and get back to doing what they love.

Research Links

Ma D, Liang Y, Wang D, et al. Trend of the incidence of lumbar disc herniation: decreasing with aging in the elderly. Clin Interv Aging. 2013;8:1047-1050. doi:10.2147/CIA.S49698

Martínez-Quiñones JV, Aso-Escario J, Consolini F, Arregui-Calvo R. Regresión espontánea de hernias discales intervertebrales. A propósito de una serie de 37 casos [Spontaneous regression from intervertebral disc herniation. Propos of a series of 37 cases]. Neurocirugia (Astur). 2010;21(2):108-117.

Kim ES, Oladunjoye AO, Li JA, Kim KD. Spontaneous regression of herniated lumbar discs. J Clin Neurosci. 2014;21(6):909-913. doi:10.1016/j.jocn.2013.10.008

Chiu CC, Chuang TY, Chang KH, Wu CH, Lin PW, Hsu WY. The probability of spontaneous regression of lumbar herniated disc: a systematic review. Clin Rehabil. 2015;29(2):184-195. doi:10.1177/0269215514540919

Pape JL, Brismée JM, Sizer PS, et al. Increased spinal height using propped slouched sitting postures: Innovative ways to rehydrate intervertebral discs. Appl Ergon. 2018;66:9-17. doi:10.1016/j.apergo.2017.07.016

Belavý DL, Quittner MJ, Ridgers N, Ling Y, Connell D, Rantalainen T. Running exercise strengthens the intervertebral disc. Sci Rep. 2017;7:45975. Published 2017 Apr 19. doi:10.1038/srep45975

Pilates 101 - 7 Minute Home Workout Video

How to develop mental resilience after an injury

We have an acronymn for the physical side of injury - RICE (Rest, Ice, Compression, Elevation) that works well and is easy to remember.

But the mental side of how you deal with an injury is arguably more important.

Our beliefs, attitudes and emotions about the situation can set the stage for effective healing to begin.

That is why we have come up with another version of RICE, a simple mantra you can go through in your head in less than a minute, and hopefully set the stage for a positive healing experience after an injury.

• Resilient - the human body is an incredibly resilient self-healing machine

• Intuitive - allow space and openness to listen to the wisdom of the body

• Capable - what’s your current capacity relative to the demands of your sport and life?

• Equanimous - calmness and composure in a difficult situation

Please see below for a more detailed breakdown of each word.

I hope this information empowers you to lead a healthy and enjoyable life, with confidence in your body.

Dan

Warning: if you are unsure why you are getting pain, please ensure you consult with an appropriate health care provider.

Resilient

Our bodies our are incredibly resilient and robust.

Think of when you have accidentally cut yourself - and how quickly it heals within a few days, without you even thinking about it.

Our bodies are essentially powerful super healing machines - our job is to provide the best environment to support the process.

Find an exercise or movement that doesn’t aggravate your pain or injury and focus on that until you feel better, keeping your blood pumping and endorphins flowing.

Vulnerability and Fragility

One thing injuries can do is make us feel vulnerable and fragile.

Fearing further injury can lead us to over-protect (see below).

This can lead to less movement, in an attempt to protect the area from further damage.

It can also lead to increased muscle tightness by bracing to protect, which can lead to some compensations and stress in other parts of the body. 

Of course some rest and recovery is needed in the short-term.

At the other end of the spectrum, some people are really good at ignoring and pushing through their pain.

So where should we draw the line between too much and too little activity?

Monitoring your symptoms during exercise and for the 24 hours following can be very useful guide (see below).

Pain up to 5/10 is considered acceptable and to be expected.

After an injury, it is natural to feel a little vulnerable.

But always remember you’re not fragile, weak or damaged.

If you’ve ever worried about degeneration or wear and tear, I would highly encourage you to read this book by Dr John Sarno. In particular the first chapter, titled ‘Structural Abnormalities Rarely Cause Pain’.

And if you need any more proof of the resilience of the human body, consider these stories:

• 102-year-old runner has no plans of slowing down

• Watch: Athlete With Cerebral Palsy Deadlifts 200 Pounds

• The Story of Turia Pitt

• 'Anything is possible': Eliud Kipchoge on his sub-two hour marathon record

• This 70-Year-Old Ran a 2:54 Marathon

• 5 Epic Feats of Athletic Endurance

Intuitive

Your Body Always Knows What To Do And It’s Always Trying to Communicate With You - Are You Listening?

It can be confusing when you have an injury… but if you allow some space and openness to listen to the wisdom of the body, you may have a better chance of hearing it’s message.

As for most things - a balance of logic and intuition goes a long way to getting you on the right track.

In this day and age with technology and devices so pervasive, it is becoming much more challenging to maintain strong lines of communication with the body.

We are living in our heads so much, the body has almost become an abstract concept!

Interoception

Interoception is the ability to sense internal messages coming from the body, such as heart rate, hunger, nausea and emotions.

Interoception also refers to being able to feel sensation coming from muscles such as tightness and tension.

What is very interesting is that the researchers have shown that people who have had chronic pain, stress or trauma in their lives have a decreased interoceptive ability.

This means, they have a limited to ability to hear what they body is telling them and change their behaviour appropriately, setting the stage for injury to occur.

We all have the ability to increase the capacity of our internal awareness.

It takes an investment in time, practice and curiosity.

Tips to improve interoception:

• develop a mindfulness based practice such as yoga, pilates, gym or running

• spend time in nature walking barefoot

• get regular massage / dry needling

• use a foam roller / spikey ball

• learn about heart rate variability training

  Just a warning, as you increase your interoception, you may become more acutely aware of things going on in your body. This is a normal process, but can be a little overwhelming at times.

  Working with a health care professional or teacher who is sensitive to your needs can help accelerate your powers of intuition and interoception in a safe way.

Never forget you know your body best and what works and what doesn’t.

Have trust and faith - there is a deep wisdom encoded into every cell in your body, based on millions of years of evolution.

For a really great read on interoception, click here.

Capable

Capability = CAPACITY minus DEMANDS

Always keep this picture in mind!

What’s Your Current Physical Capacity Relative to the Demands?

Some research would suggest around 80% of injuries are due to ‘too much too soon’ where the demand is far greater than your current capacity.

You may need to more gradually stress your tissues and allow time for adaptation to occur.

“Long term consistency trumps short term intensity” - Bruce Lee

For more detailed info on load management please see here.

“Always be building your capacity”

In life we know there will always be times when you will be getting sick, under extreme stress (or fighting the threat of a global pandemic).

So when things are relatively calm and stable, it is worth investing time and energy into building your physical and mental capacity so you are able to effectively deal with the challenges that will come your way.

Equanimous

Equanimity = calmness and composure especially in a difficult situation

This is probably the hardest one to master.

Could you re-conceptualize an injury from a problem to be avoided to an opportunity to learn more about your body and become more robust and resilient?

Equanimity is a revered emotion and an attitude that is cultivated by a number of major religions and ancient philosophies.

Treat success and injuries the same.

Develop a growth mindset.

Injury isn’t always a bad thing - story of the horse who ran away - bad luck vs good luck - it doesn’t actually exist.

Everything happens for a reason.

Ultimately injuries provide us an opportunity to learn more about our bodies and grow stronger and more resilient in the process.

Worrying about an injury is a low-vibrational state.

Figuring out what you can put your energy into will bring about a faster resolution of symptoms as well as taking your focus off any negative emotional states.

So next time you have an injury, please think RICE:

• Resilient - the human body is an incredibly resilient self-healing machine

• Intuitive - allow space and openness to listen to the wisdom of the body

• Capable - what’s your current capacity relative to the demands of your sport and life?

• Equanimous - calmness and composure in a difficult situation

If you have found this useful, I’d love you to let me know by leaving a comment below.