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The best things to do for a bad back pain episode has challenged people and medical doctors for generations. In the 1980’s bed rest and even a hospital stay was the best option in the USA. In England traction was thought to be the answer to a tight contracted back, that was to gradually stretch it out. Some people had two weeks of traction as the best medical care. Today in England the main medical approach is to provide anti inflammatories and mild over the counter pain killers, with a physiotherapy referral (within a few months). The physiotherapy approach to back pain is to provide reassurance at first. Typically an episode is bad for 3-5 days and can be felt to some degree for 4-6 weeks. People’s episodes are normally over by the time a hands on approach from the NHS is provided. The way the first back pain episode is cared for can have a knock on effect to future pain episodes. If you don’t get fixed at first it just keeps on coming back until you either get fixed or get used to having back pain episodes. 1-3% of back pains will have a sinister aspect eg a red flag such as a collapse fracture
It has been known for 15 years that anti inflammatories are enzyme inhibitors that alter the natural balance between cyclooxygenase (COX) and lipooxygenase (LOX) enzymes. Altering any natural balance creates a drive to re-balance leading to more COX enzyme increasing inflammation after 2 hours. Yes there is a decrease in inflammation in the first 30-60 minutes, then a rebound increase in inflammation begins to develop surpassing previous inflammation levels at about 2 hours after taking the NSAID (Ibuprofen). The marketing of anti inflammatories is highly suggestive having a strong impact on a lot of people.
Recommendations are now recognising that for acute low back pain the best approach is to rest for the first day, then allow yourself to move around as normally as possible, light duties and slow. Consider Chiropractic Care to help (not only this episode but also future episodes – having chiropractic care for your first episode can actually prevent the next episode form occurring).
According to advise from Harvard University medical Doctors, Chiropractic Care is a very good idea. See for yourself at http://www.health.harvard.edu/blog/heres-something-completely-different-for-low-back-pain-2017070611962
A new Cochrane review of the best exercises for people with chronic back pain has been published this year (Jan 2016). The review is a meta analysis showing that there is no one best exercise for back pain yet it is important to exercise to help yourself. The type of exercise may well come down to your preference or possibly your practitioners experience or preferences.
How long do you continue until you throw in the towel; how long is long enough to know if your current type of exercise is helping? According to the new Cochrane review exercise programmes can last up to 12 weeks.
When I think about forming a habit I see that it takes humans between 29 and 230 days to form a psychological habit. When I see that body tissues can take 3 months to co-ordinate with each other in a new movement pattern I think 12 weeks seems that is only stage one of an exercise programme. When we first kinesthetically understand a movement in our body we are looking at a 12-16 week time frame. 12 weeks cannot include strength (posture), endurance, speed or co-ordination.
The internal arts of exercise such as Tai Chi, which has been shown to help chronic back pain is said to take 1000 hours of practise to become a beginner and 10000 hours to become adept. The internal arts help you to develop an representation of your body in your imagination. We actually have several body maps in our brain e.g in the basal ganglia (brain stem), the cortex, thalamus and cerebellum. This means that our internal perspective of our body can be altered by stimuli that does not originate from the body. This perhaps is why yogis have many different representations of their body; physical body, emotional body, spiritual body etc…
An exercise programme needs to make sense, be worthwhile affordable and accessible. Starting out with fascia first chiropractic to help your body get there quicker and to educate and reassure you that pain is not something to automatically fear; you could be embarking upon a realistic plan of rehabilitation. Walking the fine line of adaptation and neuroplasticity.
At first learning about the human body can be confusing at best, for the human body is a complex thing to attempt to understand.
In 2007 prominent physiotherapists published a paper on regional interdependence. This is a type of pain that occurs at a distant site to the root cause of pain (nociceptive). E.G that the thoracic spine can be the cause of neck pain, and a not so obvious one that the foot can stop head rotation short. Essentially almost any part of the body can affect any other part as we are well interconnected (hopefully!). The body in fact is bidirectional within itself (Tech bit: in a lower motor neurone way). The knee could cause the painful low back experience of an individual but does not give any pain at the knee. Regional Interdependent pain is different to referred pain as referred pain had been mapped and is known. In a case of interdependent pain the body worker assessing you would have to understand the link in order to help you with your problem. If the site of pain is treated then the problem can be made worse in the case of interdependent pain. Body workers such as chiropractors have ways of identifying areas to treat that are not pain based. Which is why some people have regular care; gaining benefit without the pain involved in a flare up.
Chiropractors are educated intellectually and trained in manual procedures differently to specialist manual physiotherapists, hence why in the case of a person with regional interdependent pain, we find that tacitly the concept is already part of chiropractic care plans to help musculoskeletal pain experiences. In other words: My pain does not always signify the body part that requires treatment. There will be an order of care in your chiropractic care plan that involves you finishing the course of treatment. Chiropractic is more than a quick click.
Chiropractic’s famous first adjustment story is recognized each year by the Chiropractic profession when we are reminded about our roots. There is much hyperbole about the story as one can imagine that occurs when embellishment meets embellishment and enthusiastic well meaning generations alter the story slightly to fit with their momentary feelings whilst retelling the story. This process repeated many times over gives a sense of mystery. The stuff every good story is made up of. For example this year the ICA have released their version of the story as:
‘On this day, 118 years ago, Dr. Daniel David Palmer administered the first specific chiropractic adjustment on his patient, Harvey Lillard in Davenport, Iowa. Dr. D.D. Palmer delivered this historic first chiropractic adjustment with the specific intent of realigning a malpositioned vertebra on the patient, restoring its normal position, and Harvey Lillard, who had lost most of his hearing 17 years earlier, noted his hearing swiftly returned under Dr. Palmer’s care.’
I personally have had two people have vast improvements in their hearing and know of 5 other chiropractic patients that have had vast improvements even two brothers under consultant supervision within the NHS who had years of tests and investigations as to their hearing deficits. The real life examples are there but few and far between to really ‘hang one’s hat on’.
Not only was the story of DD Palmer rare but a stroke of luck as described by Life University in their reconstruction of the story told by DD Palmer himself(!) http://www.youtube.com/watch?v=kSfQQGAkb7k In this telling the story is different to the intended and ‘specific’ nature of the first adjustment by DD Palmer. Here the story is that DD Palmer was saying goodbye to Harvey Lillard and on the staircase gave him a truculent slap on the back with a large book. A few days later Harvey returned to DD unannounced and said his hearing was significantly improved. Chiropractic had a chance beginning.
DD seemed to have gotten lucky and then set to work to explain what he observed. There is not mention of how many other people he tried to slap on the back with a book who had hearing problems or of his attempt to replay the context within which the slap was given. DD immediately set to work on the spine and tried to be more specific in his net application of force to Harvey. Further ‘ adjustment’ restored the rest of Harvey’s hearing (or now that Harvey was primed his expectation was to create the same state and rapport and he’d naturally get better). This is a great story and one that has set the tone of the profession from bone setting (DD had training in) into the muti technique conglomerate of done by hand that is helping millions of people get well today.
I have a particular view based upon how our practise is set up today that the first adjustment was as much about the context, meaning, intent, environment, priming and belief as much as it was the spine to ‘align’… Ever since Chiropractors have been stuck on just the spine. By using nothing more than interaction, simple props and rapport humans can help other humans over come just about anything as long as their culture and/or they think it is possible to get well (hope).
In my mind there are a myriad of explanations for why Harvey Lillard had an improvement in his hearing. DD Palmer explored many and found that adjusting the spine had a miraculous effect. Just as alcohol could fuel the first riders in the Tour De France times change, perceptions, knowledge and culture changes. Thus today the founding principles of Chiropractic cannot be held onto. They can however be kept as a comforting story about the beginnings of the largest non drug health care profession in the world. From such chance beginnings people have a way of being healthy that does not have to involve drugs. Education, knowledge and standards are changing and those for Chiropractors have changed too.
In yester year there may have been a singular adjustment that was considered the reference point that made a difference and lead to the ideas of administering an adjustment. Contemporary Chiropractors realise that the same rules do not apply today as they did one hundred and 18 years ago. The first subject may have been ‘subluxed’ at his T4 segment or his atlas (depending upon which story version you hear!) whereas today a look into the nervous system of a person may look something like:
Symptom: upper cervical pulling sensation that leads to an almost unbearable migraine that is not totally relieved with valium, pain killers and anti-inflammatories. Imaging was unremarkable.
Chiropractor interprets: Occiput dysfunction (CN10 vagus nerve), no sacral dysfunction or lower extremity dysfunction, CN9 motor dysfunction at back of throat, cn12 tongue motor dysfunction, cn11 traps weakness and opp scm (hemisphericity?), along with external ear pinna sensitivity (cn9), shimizu reflex, larger vessels in the eye, eye press dysfunction in changing heart rate; corneal reflex is ok so just cn10 dysfunction etc. Chiropractors continue along a deductive line of thought based upon the idea that somewhere the body is telling the brain the wrong information creating a Chinese whisper (subluxation) that creates an unconscious reflex response from the brain to create the sensation of a symptom. The point is that examination today is in more detail than it was in 1895 by a long way due to the advances in science and the understanding of the brain body and body brain connection.
Some chiropractors can rest on their laurels and only follow lines of possibility that are similar to the founding principle of everything comes from the spine. Even though this line of enquiry into human health was reinforced by Henry Windsor MD in 1921 for just over a decade who demonstrated that natural causes of death correlated exactly to the controlling level of the spine 99% of the time in cats dogs and humans. There have since been advances in knowledge around causes for changes in human health that are not considered a disease process. For example: development (attachment), interaction, genetics, trans-generation habits (copying conscious and unconscious aspects of influential people), environment, activation of HPA axis (trauma), culture, religion, mechanical injury, insidious injury, infectious load, fitness, family commitments, pressure of life, relationship with yourself, diet, hours driving, hours sitting, free time, spiritual development, social group, and knowledge are all factors to take into account when considering the health of a person’s nervous system.
Stories convey meaning and enable us to feel. We can all recognise a pleasant feeling over an unpleasant feeling and thus a good story from a bad. Altrusim / helping the greater good of mankind is a great theme to help Chiropractors be reminded of why they are chiropractors and not a time to return to the (original) adjustment being king and everything is from the spine! May the chiropractic profession expand, spread the modern word and help millions more people.
Sitting for long periods doesn’t help people feel good naturally but is this really a problem or are some people moaning?! When we sit we sit on our gluteal muscle group as well as the backs of our legs (Hamstring muscles), possibly sit bones and greater trochanter (hips). Recent findings about the gluts has changed professional opinion about the gluteus maximus in humans. It was thought to be different to monkeys but now is thought to be very similar to that of monkeys with almost identical origin (where the muscles starts) and insertion (where the muscle goes to).
What I can deduce from our current anatomy is that we’d have had a functional element to the gluteus maximus other than a cushion way before even the first chair or log was sat upon. Our anatomy suggests that we have a sling system (roughly) incorporating the tensa fascia latae, gluteals and sacroilliac ligaments; meaning we have the tools within our body to squat down and be supported by a sling of tendon know as the IT Band or Tensa Fascia Latae (TFL).
The ‘natural squat position of a child and that of a monkey are very similar. When we use a chair we do not need to hang supported on our natural sling and thus do not have the muscular co-ordination required to hold the body in the seated shape (within Earth’s gravitational field). Thus the brain will be getting ‘bum(!)’ information and given enough time will not be able to coordinate sit down or stand from sitting efficiently. It is common thought that people who have had more time on the planet cannot sit to stand or stand to sit due to age; this concept I dispute. We simply do not practise or reinforce the co-ordination of movement required to sit down and stand up efficiently and thus we will over time go more and more wrong. When we go wrong we cause wear and tear, pain and tight or slack musculature.
By squatting down we are resembling how monkeys will ‘sit’ and how our anatomy can increase circulation in our hips rather than reduce circulation by sitting on our gluteus maximus. It is a medical norm to expect to see some wear and tear (coxarthrosis) and reduced circulation in a man of only 40 years of age! I think this is a medical norm because medics are looking at the smallest parts of physiology and have not yet begun to understand the machinery (anatomy) of the body.
I believe that when we become uncoordinated it will be the cause of pain in cases where there is no obvious injury 97% of the time. An insidious onset for back pain is presumed to be due to age. Medicine falls so far short in understanding the body mechanics that it would be like going to see a caterer to help you put up a marquee. There are some overlooked aspects of muscles that can lead to musculo-skeletal dysfunction which are easily explained without having to describe a primary injurious mechanism. People who have had back pain or treat people that have low back pain are often fixated on the cause. This day and age if it isn’t cause and effect then it must be a trick or something sinister! Whilst almost every western person is having to perform sit to stand and stand to sit I suspect that very few are practising how to perform this movement. To condition our body to be strong in a particular way we need to repeat the action in an intensity that is enough to create adaptation but not enough to injure. The best posture to sit in is a squat. How you get to a squat position in my opinion is through the Qi Gong wall squat technique as this enables us to integrate our body from head to toe. Other variations on a squat movement may concentrate force at particular points of the body. Ideally for health one would look to integrate their whole body in a given movement. Through integration we reduce thixotropy and improve proprioception.
The time it takes you to learn the wall squat techniques can vary from a few weeks to a few years depending upon your current ability. The point of the exercise is to coordinate your whole body within the movement and not to simply reach the lowest point. If you can only squat down a very short distance like many out there will find, then begin with a short distance and with practise within your chosen personal limits increase the distance you can squat. The only thing to improve against is your previous ability. If you are not improving then you are likely getting worse as our dynamic body and brain do not hold static ability. The art of integration of your body is much more important than copying the full movement. If it doesn’t feel right then odds are it isn’t! consult an expert who can help you to reach the goal of always being able to sit to stand and stand to sit in a whole body integrated way so that you are aware of how your body works together through your own internal representation of your body through your mind’s eye. The internal art of movement is something being slowly lost from the human race which will lead to more focus on accumulating stuff and experiencing more pain. Movement and a chiropractor like me is what your body wants …