We are happy to announce the release of Pain Free Back for the iPhone 4 with improved graphics, improved algorithms and improved stability!
Coming next: special features that have been requested by users!
I saw a patient today who presented with complaints of a tight hamstring. Further investigation revealed that he had bilateral pain, and occasional peripheral pain below the knee in addition to the tight hamstring.
Immediately, my thoughts went to a central problem rather than the pain in the hamstring being caused by a hamstring issue.
Further testing revealed good hamstring length, good hamstring strength and a generally negative neurological exam.
Palpation suggested that his hamstring is normal.
So I asked him to go back to his doc and to ask for an MRI of his lumbar spine. The reason is that he has a central problem. How else could he develop bilateral pain even if it was and is worse on one side? Beyond that with no significant evidence of neurological involvement, and since his pain has been present for more than 5 years, the fact that it is worsening now made me ask him to go get an MRI. There is always the possibility that he is growing something, although it might just be a disc bulge that is causing bilateral pain. At Sports Reaction Center, we perform a complete evaluation including a functional screen and a neuro screen as well as what is known as a Cyriax evaluation designed to reveal the tissue in dysfunction.
So the moral of the story is that unless you can identify a specific insult to the hamstring, there is a good chance that that pain in your thigh originates more proximally.When in doubt get more data. A good PT or Physiatrist can help you sort out your issue.
A motion segment is the vertebra, the disc, and the next vertebra. When you lose disc height, the segment can sheer. Sheer in the lumbar spine is not a physiological movement. sheer produces a change in the location of the axis of motion, and that leads to muscle guarding and pain. It is fair to say that sheer in a motion segment equals instability. an unstable motion segment can make the pain tricky to resolve or pin down.
For instance, I saw a patient this past week who experiences pain at night – which is very unusual for mechanical lower back pain, but she sleeps on a soft bed. As she relaxes into her sleep, the pain increases because the segment sheers, creating pressure on pain sensitive structures.When she is up and around, she has no pain, and is even able to engage in activities such as horseback riding. But the pain at night wakes her from sleep. Usually pain in a non-weight-bearing posture would be a red flag for requiring further investigation, but in the absence of findings, it is most likely that her pain originates in an unstable segment, and this was confirmed by physical examination.
Nevertheless, it is quite challenging to stabilize an unstable segment though, because the instability is mechanical, while the stability has to come from muscles. The deep paraspinal muscles multifidus and rotatores for example, are responsible for providing stability to motion segments, and can be over trained allowing dynamic stability to reduce mechanical instability. In addition, this person has to restore normal functional length to her hamstrings which are tight, and her thoracic spine which is restricted. Taking the pressure off the lumbar spine for motion reduces the tendency to sheer. Coupling that new flexibility with core stability drills and in particular, deep rotator muscle drills will sort this problem out.
It seems impossible. The idea that you should walk when you are in pain. But the thing of it is that you should. Simple as that.
The literature is clear on this point, bed rest does no good, and people who maintain their usual activity schedule, seem to do better.
Physiologically, the best form of exercise is simple aerobic exercise. Walking is perfect. When you walk, in addition to the benefits of aerobic walking, improved circulation, improved aerobic capacity, lowered blood pressure and so on, the step after step after step results in the muscles around the spine, the deep muscles, contracting and relaxing repeatedly which leads to reduced muscle guarding.
When in pain, the deep muscles contract to protect the injured part. There are various explanations for this, but the explanation I like is that because there are no valves in the veins of the spine, which means that venous blood can flow either way, the muscles contract to prevent the circulation of a bacteria, and also to protect any damaged or injured structures. Muscle guarding is governed by nerves that can cause them to contract by levels as far away as 5 levels. One of the most important things I think that you can do when in pain is to do all you can to reduce and or prevent the muscle guarding. Muscle guarding itself turns into a secondary problem of ischemic pain caused by the accumulation of metabolites secondary to the prolonged muscle guarding.
Aerobic walking is one way to do that , and ice is another. See the earlier post about ice.
I think that you should go for a walk every day, twice or three times a day for about a half hour at a pace that causes you to work up a light sweat and your breath to be a little deeper. You will feel great if you do.
In the Western world, it is very common for people to develop a “lower cross syndrome”. This is a mechanical circumstance where tight hamstrings, tight hip flexors, weak abdominals and a sway back conspire to cause lower back pain. In a culture that sits a lot, doesn’t exercise much and has a high incidence of lower back pain, it is common to find lower cross syndrome at the root of the symptoms.
The best “treatment” for this syndrome to to combine stretching of the hip flexors and hamstrings with strengthening of the abdominals, or core strengthening. The core program can be found in the LITE version of our app. The stretches are to be found in the full version of the app.
For long term back health, combining core strengthening with lower extremity flexibility is key. In our clinic, Sports Reaction Center in Bellevue, WA, we have successfully treated thousands of lower back patients over the years using these strategies. In the absence of disc herniation or other mechanical causes of lower back pain, this simple strategy can solve your problem.
I am often asked the question about heat vs ice. First let me say that there is a lot of mythology about this question. My opinion is simply based on the science.In the clinic, I answer the question this way:
Heat works to reduce pain through a cutaneous (skin) reflex that is inhibitory to pain as long as the receptor is being stimulated. The problem is that the receptor accommodates to the heat and so the heat source has to get hotter and hotter in order to inhibit pain. One risk in using heat to treat pain is the possibility of a deep second or even third degree burn.
Ice on the other hand, actually produces anesthesia after it has been on for a time. Ice reduces swelling, and ice causes muscle guarding to cease. Ice also lasts for long after the ice has been taken off, whereas heat stops working as soon as it is removed from the skin.
The secret to the safe use of ice is that you need to combine ice and water to ensure that the temperature stays at O degrees Celsius. Ice plus water in a plastic bag on the skin for a half hour will numb the muscles of the back, reduce pain for up to two hours and will reduce swelling. You can ice every two hours for half an hour.
Ice is your friend, but make sure that you use ice plus water so that your don’t get freezer burn.
1. Keep moving…bed rest is the worst idea.
2. Ice is your friend: Prolonged ice in the form of crushed ice PLUS water in a plastic bag on the skin directly for a half hour to an hour.
3. Avoid prolonged sitting. Get up and move around
4. Use smart lifting mechanics
5. Do the Phase One exercise program prescribed for you (check out our app to help you sort that out!)
6. Be cautious first thing in the morning.
7. See your physician in the even you have any of the RED FLAG signs
I am often asked questions about morning pain. If you have pain that is worse in the morning and seems to get better as the day goes on, before worsening again at the end of the day, then your pain is most likely discogenic pain – or pain that originates with the intervertebral disc.
The disc is like a jelly doughnut in that it is made up of two structures, the nucleus (the jelly) and the outer shell, called the annulus. The annulus is made up of repeating layers of tissue, similar to an onion, with the nucleus in the middle like the jelly in the doughnut. The natural history of the aging of the discs results in gradual failure of the annulus, so that by about age 25, the nucleus is starting to push out and create a bulge in the disc, that itself can be painful.
Now with that in mind, you can see how the bulge develops, and you now need to imagine that the nucleus grows and shrinks depending on the weight bearing status. I say this because the nucleus is made up of molecules that are hydrophylic, which means that it attracts water, it does more than attract water, it actually binds water and as such, grows in thickness. This happens in a non-weight bearing status which is usually at night.
Because the nucleus is under more pressure first thing in the morning, any bulge that occurs is more likely to cause pain since the pain sensitive structures will be under greater distress. The pain subsides as the day goes on though, because as your physical weight puts the disc under pressure, then nucleus loses water.
You might remember the SkyLab astronauts, who, when they returned from space, and to do so early because they out grew their space suits in that ant-gravity environment. This occurred because without weight bearing, the discs just got thicker and thicker as the nucleus continued to imbibe fluids.
Morning pain occurs then, because the disc starts out each day with greater intradiscal pressure after a night if absorbing water. If this is your experience, then you need to start out each day with greater caution.
- Use good mechanics
- Face what you are doing
- Avoid bending and lifting activities
- Be careful exerting pressure while on the potty
As the day goes on, and the pain subsides, you can relax a little, but you still need to be cautious because even though the pain is lessened, the disc is still susceptible to bulging. Just remember, that back pain is episodic, which means it comes and goes, and the best treatment is prevention.
The data says that you should stay active, use good biomechanics to do things like lift and carry objects, and avoid prolonged sitting.