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MRI scans for low back pain

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MRI scans for low back pain – when are they useful.

Lower back pain is common with almost all of us suffering from it at some stage in our life. Most times it settles fairly quickly and other times it responds to treatment. Scans or investigations usually in the form of MRI or CT are recommended when it doesn’t settle in an acceptable timeframe or your physio and doctor indicate it is recommended earlier.

low back pain scans and diagnosis newcastle physiotherapy

The purpose of this blog is to reduce fear or concern if you have scans that show pathology. Although any pathology seen on imaging can be responsible for your pain, it doesn’t have to cause pain. The following table is from a systematic review in the American Journal of Neuroradiology. It looks at lots of research studies where they have scanned the lower back in people who don’t have any pain. The table below shows the % of people that when they had scans they found pathology BUT these people did not have any symptoms or low back pain. In other words pathology is a common finding in people who do not have lower back pain.

20yrs 30yrs 40yrs 50yrs 60yrs
Disc Degeneration 37% 52% 68% 80% 88%
Disc Bulge 30% 40% 50% 60% 69%
Disc Protrusion 29% 31% 33% 36% 38%
Disc Annular Fissure 19% 20% 22% 23% 25%
Facet joint Degeneration 4% 9% 18% 32% 50%
Brinjikji et al, 2015. Systematic Literature Review of Imaging Features of Spinal Degeneration in Asymptomatic Populations. Am J Neuroradiol 36:811–16 Apr

The highlights in the table show that 37% of those in their 20’s had some disc degeneration but no pain. In the 30s age group it had increased to 52% but again no pain. If a scan is likely to show normal pathology associated with age but doesn’t mean you will have pain and it’s also not going to change the treatment, then scans are not recommended. So if you do have lower back pain, scans are not usually recommended in the early stage.

If you have low back pain, firstly you should manage the pain with simple analgesics such as paracetamol; stay active as tolerated and occasionally use positions that offer short term relief. In acute low back pain, physio can help with the posture and movement means to reduce pain.

There are times when you do need to have scans straight away and your doctor or physio will identify those occasions. For example if your pain is severe, worsening or if you experience neurological symptoms such as weakness, tingling or numbness, then you need to be assessed by your physio or doctor.

If you have back pain and it is affecting your ability to be active then contact us for an appointment. We believe in an active approach to treating low back pain. Contact us on 4921 6879.

Lifting children and low back pain

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A lifting tip for our parents with kids under 5. Did you know the level of load when NSW WorkCover injuries are reported to occur with a seated lift? Anything above 4.5kg! Translate that to the average weight of a 2 year old child who we often lift onto our laps when we are seated. The risk of hurting your back when lifting is relative to many factors including how much bending and lifting you have done lately; how much or little exercise; and your level of stress. If we can advise one thing to reduce the chance of back injury it relates to not lifting from the side in a seated position. This creates a twist or rotation force whilst lifting a load in a bent back (seated) position and has much greater forces on the lower back. Lifting children and low back pain are commonly associated but can be managed better with good movement habits.

Higher risk
Consider changing your habits when lifting your kids. Do they have to be lifted? If so, stand up or kneel onto one knee if possible; let then climb up if they can rather than you lift them; or turn towards your child or get them to come directly in front when lifting – chest and hips facing the same direction to avoid twisting the back.
Less risk
Simple strategies work the best to prevent lifting related low back pain. However the stress of looking after children sometimes also makes it hard to think about the simple strategies. That is when taking some time for yourself to go for a walk is important.

Shoulder dyskinesia – does it cause shoulder pain?

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shoulder pain and dyskinesia

Shoulder pain is a common problem. It is one of the top four reasons why people see their physiotherapist. The scapula (shoulder blade) is commonly blamed for causing someone’s shoulder pain. However, our understanding about the relationship between shoulder pain and scapula motion has since improved with new research findings.

When you perform a shoulder movement, the scapula follows the arm bone in a particular pattern of motion. Scapula dyskinesia is when this pattern is considered abnormal. When it gets tricky is when we try to determine what exactly defines ‘normal’ movement of the scapula. Our current understanding of ‘normal’ has been developed based on studying people with non-painful shoulders. It was thought for a long time that scapula dyskinesia causes the shoulder pain, but it might not always be the case, in fact it could be the other way around!

The research has been able to consistently show us that shoulder pain can actually cause dyskinesia. That is, people who had no pain and no dyskinesia were injected with a painful substance and this then led to those funny looking movements of the scapula. Therefore, scapula dyskinesia may in some cases be a short term response to acute shoulder pain. When the pain persists beyond the acute phase, the presence of scapula dyskinesia might actually be causing more problems, preventing the shoulder pain from improving.

Our physios believe that an important part of the shoulder examination includes assessment of scapula movement to determine if it is a contributing factor to the patient’s pain. If the scapula is found to be a contributor, treatment can be directed towards it and may involve:

  • Manual therapy to correct tightness that might affect scapula movement
  • Exercises that teach you how to change the way you move your scapula
  • Taping the scapula to help it move differently
  • Strengthening exercises for the scapula and rotator cuff muscles
  • A functional exercise program that helps you achieve your goals

But what if you have scapula dyskinesia and no pain?
The research is not yet clear whether scapula dyskinesia causes pain in the general population. There are some studies in high level, finely tuned athletes that show that the presence of scapula dyskinesia is linked to developing pain in the future. Clinical experience says that if one scapula moves differently to the other, consider trying to change it with some strengthening exercises that lower your risk of developing shoulder pain in the future.

Key points:

  • Pain can cause scapula dyskinesia
  • If you have pain and want to know if your scapula motion is contributing or…
  • If you know you have a scapula that moves in a funny way and you’d like to know more about it:

Then call us on 49216879 and we can advise what is the best way to manage it.

Low back pain … learning to take control yourself

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Low back pain

A recent journal article in the Medical Journal of Australia* prompted this blog to encourage our clients to learn more about how they can take control of back pain. Low back pain gets 80% of us over our lifetime. It often resolves without treatment in the first week or two but recurs in up to 70% of cases. It is also common in adolescence (up to 50%). The assessment of back pain must consider the mechanics or movement relative to the muscles and spine itself however red flags and biopsychosocial factors are equally if not more important.

Red flags are indicators of medical conditions (rather than musculoskeletal cause of back pain) that need to be considered via assessment and sometimes GP referral. The diagnosis process sometimes involves investigations via Xray or MR scans which is important but comes with risks of opening a pandoras box of what may be causing the pain (e.g. knowing there may be a problem with our spine often adds to the psychological side of how pain can persist, when in fact we shouldn’t be worrying about most of the findings on scans). It is generally understood that in a small % of cases (usually <20%) a problem identified on investigations can be related to the cause of a person’s pain. In the rest of people with back pain the findings do not correlate with what is causing their pain.

For the 80% which is the majority, the word biopsychosocial is now generally applied to understanding the reason for a person’s back pain. Yes we still need to rule out the red flag problems and the persistent mechanical back pain coming from the musculoskeletal system. But the 80% of people with low back pain need to consider the many contributors that are often psychological, social and environmental / lifestyle factors. These must be considered in taking control of back pain. Getting a good opinion early on that considers all of these factors is essential but sadly is not common enough.

Good things to remember with low back pain:

  • Getting active helps a lot of people take control of pain. The reason why can be complex but it works … you just have to find the exercise that suits you best.
  • Stress is a big factor with persistent pain. Just considering this is a start towards managing the problem.
  • Surgery is rarely the answer for low back pain.

* Atkinson & Zacest MJA 204 (8), p 299-300, 2 May 2016

ITB and knee pain in runners

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Running

Our NU Moves Physio team recently debated the current beliefs surround the ITB and how it can give you lateral (or outside) knee pain which is also referred to as ITB syndrome. Here is a simple take home message from a complex discussion.

* The diagnosis of ITB syndrome can be made clinically without investigations

* The lateral meniscal cartilage of the knee needs to be considered as a possible source of pain which may require MRI imaging. A clinical assessment will predict if this is likely.

* The most common cause of the problem is an increase in the amount of running or ‘load’ on the knee. Treatment of acute ITB syndrome must include initially managing the load to help reduce inflammation.  This is usually via modifying the running program.

* The hip is the key to controlling this problem. Most importantly the strength and timing of the gluteal (buttock) muscles need to be sufficient to hold your pelvis and leg stable enough during running. Secondarily having enough flexibility in the hip flexor muscles often helps get the gluteal muscles functioning better.

* Rolling the ITB is a common form of treatment utilised if tightness is perceived as part of the problem. If rolling gives you relief of pain associated with running or any other exercise then we cannot argue with that however understanding the reason behind why it may or may not help is the challenging part. Roll it if it helps you but make sure you start your rehab at the hip.

Exercise can help osteoarthritis

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water exercise

Do you know anyone who suffers from osteoarthritis? It occurs when the cartilage that lines the bones in your joints breaks down through trauma or age. It is most common in weight bearing joints such as your hips, knees and ankles. The greater the compressive forces placed through these joints – the greater the inflammatory response, pain and stiffness. Being overweight increases the compressive forces on our joints, making weight bearing challenging and exercise painful. Once you get arthritis pain it then becomes harder to exercise.

What is the best management of being overweight and having osteoarthritis?
There is a common misconception that weight loss occurs through exercise and physical activity. Recent studies looked at the effect of diet and exercise on weight, inflammation (measuring markers in the blood), joint compressive forces, pain, function, mobility and quality of life in people with osteoarthritis. The study reports that in fact a combination of diet and exercise provided the greatest loss of weight (10%) compared to exercise alone (2%). The group with combined diet and exercise management also experienced a better reduction in joint inflammation and pain, as well as improved function, mobility and quality of life compared to the exercise alone group.

What type of exercise is best?
A separate study looked at types of exercise undertaken in individuals with osteoarthritis. The study found that the best type of exercise for pain relief alone is water based exercise. The type of exercise most beneficial to improve function was a combination of strengthening and flexibility exercises alongside a low impact form of physical activity e.g. aqua aerobics or walking.

The general advice that can be provided based on these articles is valuable but everyone is different in the type of arthritis through to what exercise program will give the best results. If you or someone you know are suffering from osteoarthritis the best approach it to start with personalised research based advice on how to reduce pain, increase strength or decrease weight. Our physio’s at NU Moves are experts in exercise for arthritis.

* Uthman OA, van der Windt, et al. Exercise for lower limb Osteoarthritis: Systematic review incorporating trial sequential analysis and network meta-analysis. BMJ 2013; 347: f5555

* Messier SP, Mihalko SL, et al. Effects of Intensive Diet and Exercise on Knee Joint Loads, Inflammation, and Clinical Outcomes Among Overweight and Obese Adults with Knee Osteoarthritis. JAMA 2013; 310 (12):1263-1273.

Have you got persistent neck pain

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Neck discomfort

The scalene muscles could be the culprit. There are 3 scalene muscles (anterior, middle and posterior) on each side of the neck. They primarily control the side tilting motion of the head but given they also attach to the first and second ribs, can assist with upper chest inspiration or shallow breathing.

At NU Moves Physio we find these muscles become overactive and painful with excess computer / screen use. If you then add stress the posterior scalene muscle in particular tightens further which has a flow on effect in how we move the neck and further increases pain. Sometimes the reported cause is sleeping awkwardly but often this is the trigger and the cause relates back to the extra muscle tension that you take to bed.

How to control it:
1. Deep tissue massage and myofascial releases combined with thoracic spine manual therapy works immediately in reducing tension and associated pain.
2. Try to diaphragm breathe – tummy breathe. Shallow breathing into the top of the chest uses the scalenes even more. Get more oxygen deeper into your lungs and give the scalenes a break.
3. Minimise the chin poked posture at the computer (too much laptop time)
4. Lastly the most common management strategy, getting active and away from the desk. Be careful if you are really tight and start with a low intensity cardio session again with a lower deeper breathing focus (e.g. go for a brisk walk). Upper body gym sessions or high intensity runs can sometimes increase the tension and discomfort when you are really tight.

If you need help with neck pain during busy times call us on 49216879. We will reduce pain and tension and help you get active.

Aerobic vs anaerobic … what type of exercise should you be doing?

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Exercise types

There are plenty of research articles supporting both aerobic and anaerobic exercise. Some examples of aerobic exercise include running, walking, swimming, cycling etc. Types of anaerobic exercise include weight training, sprinting or any exercise bout lasting less than two minutes. After around two minutes your body’s demand for oxygen is exceeded by the body’s production of oxygen and therefore becomes more aerobic type exercise. Aerobic training is beneficial for cardiovascular health. It enhances the hearts function enabling it pump more blood to the body with each beat and also lowers resting heart rate. Aerobic training is beneficial for overall health, reducing the risk of cardiovascular disease, diabetes, and many other chronic diseases. Resistance training is beneficial for building strength, supporting and enhancing bone growth, and lowering blood sugar. This is especially beneficial for those people diagnosed with diabetes. Resistance training builds muscle which uses glucose for energy and increases insulin sensitivity. So which type of exercise should you be doing? A combination of aerobic and resistance training will have optimal effects. Make exercising enjoyable; try a range of exercise options until you find one you enjoy and stick with it. Try exercising with friends, with music or different classes. You are more likely to stick to a program if it is something you enjoy.

If you want to learn more about the best type of exercise for you contact us on 49216879. Our physiotherapists are skilled in exercise prescription for everyday casual exercise through to professional sports conditioning programs.

Exercise recommendations for healthy living

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running and physiotherapy

The current exercise recommendations for healthy living in Australia and via the world health organisation (WHO) are worth checking. Do you accumulate 150 – 300 minutes moderate intensity exercise or 75 – 150 vigorous exercise per week? Do you do muscle strengthening 2 days per week?

Think about where you sit relative to the recommendations. And while mentioning sitting, this advice is most important if you spend most of your day at a  desk. Anything is better than nothing but maintaining the recommended level of healthy exercise will pay dividends in the short and long term.

If you want to know more about the health recommendations click here. If you need help getting started with strength based exercise program give us a call 49216879.

Managing exercise, relaxation and stress

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Beach walk

Where does the time go? There are periods in life (usually the same time every year) that we don’t have time to attend to our own health in the form of relaxation and exercise. Use this as a prompt to reflect on where you are at currently. It is important to make time for both. The benefits are immense from ability to concentrate, problem solve and make better choices down to feeling better both mentally and physically.

The usual tips on getting active and managing stress at the same time are: listening to music and podcasts whilst on the gym cardio equipment, walking or jogging; exercising with a friend always helps keeps us going; playing a regularly scheduled team sports is an easy way to keep active; or starting a routine group exercise class like pilates.

I came across a different way of thinking recently which was not to focus on the time I had available as the problem but my response to being busy. It was called the 90:10 rule and challenges you to alter your mindset and increase control. 10% is what happens; 90% is how we respond. I have lots to do but I still choose what I do each day. If being busy in life is currently taking you away from routine exercise or some ‘you’ time then stop and think about the response.

Remember the exercise will make you feel better once you are in a routine. A 10 minute dose of exercise counts but 30 mins is ideal. If you find the right exercise routine you should feel more energised and relaxed rather than tired and tense. If you want to hear more about the 90:10 rule and its relevance to stress management, listen to this video from Dr Mike Evans at Evans Health Lab.