This is a great ebook written By Tim Mitchell, Darren Beales, Helen Slater &
Peter O Sullivan in 2018. The aim of this ebook is to help people understand and manage musculoskeletal pain. It is a tool for everyone (students, health professionals and people with pain).
There is no magic pill for musculoskeletal pain. However, understanding the different factors that contribute to your individual pain experience can help you optimise your management.
I have tried to sum up the first part of the ebook in two mind maps which you can download below (write better).
The second part of the ebook is characterized by case studies.
Case study 1: Acute back pain
Background
A 28 year-old bricklayer developed back pain at the end of a workday two days ago. His workday involved heavier than usual lifting. He could hardly move when getting out of bed the following morning. He reported feeling slightly better, but he was still unable to straighten up properly when standing.
His symptoms were mainly localised to his lumbosacral region, but he also had a mild ache in his right posterior thigh region. He reported pain with bending forward and when straightening up after prolonged sitting on the couch. There was some aching in his back at night and he felt much stiffer in his back on walking in the morning. Slowly walking around for a few minutes and applying heat helped to make his back feel considerably better.
He had not had any prior treatment at the time of consultation, other than using a heat pack and taking some paracetamol. He had not worked for the past two days. He had not had any investigations of his back. Other than an occasional backache after a day of physical work, he had not had any previous back problems.
Individual’s Perspective
Individual’s problem(s): He described his back pain as his main problem and this was affecting his capacity to work as a bricklayer.
Functional capacity: Limited with sitting for more than 15 minutes, putting shoes and sock on, and getting in and out of a chair or car. He was avoiding any forward bending or lifting. As an objective measure of functional limitations, his Patient Specific Functional Scale (PSFS) for working his usual job as a bricklayer was 1/10. (PSFS is a patient-specific outcome measure of functional ability rather than pain and disability. It has a good validity and responsiveness.)
Goal/Expectations: To this individual, recovery meant he would be able to get back to work as quickly as possible. He wanted his back ‘fixed’.
Diagnosis
Red flags: There were no red flags identified during the patient interview or physical examination.
Specific diagnosis: There was no indication of a specific diagnosis to explain his symptoms. Specific clinical screening tests for cauda equina syndrome and lower limb neurological deficit were normal. No spinal investigations had been undertaken, and were not indicated in this instance (based on clinical practice guidelines). On that basis, the ‘non-specific’ diagnosis of Acute Back Sprain was warranted.
Informing the individual that he had an ‘acute back sprain’ rather than ‘non-specific back pain’ is considered important. For some individuals, labelling their problem as ‘non-specific’ might be unhelpful. It may impress upon the patient that either there is nothing wrong with them or that the HCP (Health Care Practitioner) doesn’t know what is wrong with them and can’t provide a diagnosis. This perception could give rise to a negative HCP-patient relationship or a sub-optimal outcome.
Stage: Acute MPD (Musculoskeletal Pain Disorder).
Pain Features
Types: His presentation was suggestive of dominant peripheral nociceptive pain including some contribution of inflammatory process (pain at night and increased back stiffness with prolonged sitting and waking in the morning).
Characteristics: He presented with dominantly mechanically patterned pain. There were clear postures (sitting on the couch) and movements (forward bending) that aggravated his pain, as well as movements that relieved his pain (walking around). Further, the ‘response’ and ‘stimulus’ were proportionate in that his symptoms were moderately relieved after a short period of walking around.
Sensitisation: The contribution of sensitisation to his back pain was considered low, on the basis that he had fairly localised back pain, with moderate sensitivity to movement, and the loading and palpation stimuli were consistent with the clinical course and stage of the disorder. For example, forward bending, slouch sitting and localised palpation (mechanical hyperalgesia) of his lower lumbar spinal tissues reproduce his back pain to a degree consistent with his clinical presentation (symptoms were also relieved immediately on cessation of these stimuli).
Psychosocial Considerations
Cognitive Factors: There were no cognitive factors (in relation to his thoughts and beliefs) that were considered to be strongly contributing to his clinical presentation. However, his mindset of having his problem ‘fixed’ for him should be addressed in the education component of his management. Educating and encouraging him to take an active role in his rehabilitation, rather than expecting a passive ‘cure’, would be an important component of his overall management. Contribution was considered low-moderate.
Affective factors: He lived with his partner and young daughter. As his partner was not working and they had recently purchased a new house, he felt some pressure to return to work as quickly as possible. These social factors were not considered to be significant, but it would be important to address the time frames for return to work as part of management planning. Contribution was considered low-moderate.
Work Considerations
Black Flags (workplace factors) were considered to be a significant contributing factor for his back pain, as his symptom onset appeared directly related to his work. He was likely eligible to lodge a claim under the ‘workers’ compensation system. Following his assessment, he was recommended to see his general practitioner to complete the necessary paperwork and was referred to the relevant regulatory body website for information about ‘workers’ compensation injuries.
Consideration of whether any workplace factors contributed to his back pain could be important in terms of the prevention of future back pain recurrence. Communication with the treating medical practitioner and employer around his current capacity for work, treatment plans and expected time frames for recovery are key elements of effective management of individuals with work related pain. Contribution was considered moderate.
Lifestyle Considerations
He was active with his job and played recreational touch rugby twice per week. His sleep was only mildly disturbed due to his back pain. Lifestyle factors were not considered to be a significant contributing factor at this point (low).
Whole Person Considerations
There were no contributing whole person considerations identified (low).
Functional Behaviours
Helpful vs Unhelpful: He demonstrated some helpful (protective) functional behaviours. His avoidance of forward bending / lifting was considered ‘protective’ as on physical examination, repeated forward bending clearly increased his back pain. Conversely, his habitual sitting posture involved flexion of the lower lumbar spine. Adjustment of this posture via anterior pelvic tilting resulted in an immediate improvement in pain during sitting. Therefore, his sitting posture was considered unhelpful (provocative) in this context, as it was clearly contributing to increase back pain when sitting.
Impairment of control: His habitual sitting posture involved slumped (flexed) lower lumbar spinal posture. Correction of this posture improved his symptoms as described above. He adopted a similar flexed posture with squatting and moving from sit to stand. This lack of postural variability was deemed to be a likely contribution to his initial symptom onset, based on the repetitive bending nature of his work task. Hence, it was considered to be important to address this for initial symptom management, as well as prevention of future episodes of low back pain.
Pain Behaviours: There was no signs of unhelpful pain behaviours influencing his clinical presentation.
Deconditioning: Poor leg muscle endurance (sustained squat) and poor lumbar extensor muscle endurance were identified on clinical testing. This reduced muscle performance influenced his lumbar posture in functional tasks such as picking up bricks, and as such it was considered important to address for prevention of future episodes of low back pain.
Summary
This individual presented with a typical acute low back sprain, most likely related to repetitive bending and lifting of a heavier nature than usual in his job. There were no contributing factors identified that would suggest that he would not respond well to a standard evidence-informed management approach.
Clinical Decision Making
Diagnosis: Back Sprain
Stage: Acute
Prioritised list of Contributing Factors
Symptom onset related to repetitive bending and lifting of a heavier nature than usual in his job;
Habitual postures and movement patterns that involved a bias towards flexion on his lower lumbar spine;
Expectation that his back needed ‘fixing’;
Physically demanding work;
Deconditioning of lower limbs and lumbar extensor muscles.
Prioritised List of Management Considerations
Evidence informed management: education regarding a positive prognosis, keeping active and simple analgesics;
Communication with his employer;
Physical conditioning to address the physical contributing factors.
Physiotherapy Management
Pain management modalities including heat, manual therapy and gentle mobility exercises;
Education to reduce excessive bending for a few days, and advice to increase postural variability;
Training of sitting and functional postures to enhance postural variability during bending, lifting and sitting. Consider use of proprioceptive taping in the first session;
Conditioning program to address lower limb and back extensor muscle endurance;
Longer term ergonomic review of work task directly associated with his symptom aggravation;
Communication with the treating general practitioner, employer, insurer and other stakeholders as required.
Regular physical activity (during the course of life)?is associated with health benefits, including improvements in physical and mental health, as well as decreased risk of chronic disease and mortality. Pregnancy is a unique period of a woman?s life, where lifestyle behaviours, including physical activity, can significantly affect her health, as well as that of her fetus. Although guidelines around the world recommend women without contraindication engage in prenatal physical activity, fewer than 15% of women will actually achieve the minimum recommendation of 150 min per week of moderate-intensity physical activity during their pregnancy.
Over the last three decades, the rates of pregnancy complications such as gestional diabetes mellitus, pre-eclampsia, gestational hypertension and newborn macrosomia have risen dramatically most likely as a consequence of rising rates of maternal obesity.
Who should be physically active during pregnancy?
Alle the women who do not have contraindications that would prevent them from engaging in physical activity. Women with absolute contraindications may continue the usual activities of daily living but should not participate in more strenuous exercise. Women with relative contraindications should discuss the advantages and disadvantages of moderate-to-vigorous intensity physical activity with their obstetric care provider.
Absolute contraindications
Relative contraindications
Ruptured membranes, premature labour
Recurrent pregnancy loss
Unexplained persistent vaginal bleeding
History of spontaneous preterm birth
Placenta praevia after 28 weeks gestation
Gestational hypertension
Pre-eclampsia
Symptomatic anaemia
Incompetent cervix
Malnutrition
Intrauterine growth restriction
Eating disorder
High-order multiple pregnancy (eg, triplets)
Twin pregnancy after the 28th?week
Uncontrolled type I diabetes,uncontrolled hypertension or uncontrolled thyroid disease
Mild/moderate cardiovascular or respiratory disease
Other serious cardiovascular, respiratory or systemic disorder
Other significant medical conditions
Recommendations
All women without contraindication should be physically active throughout pregnancy.?Strong recommendation, moderate-quality evidence.
Pregnant women should accumulate at least 150 min of moderate-intensity physical activity each week to achieve clinically meaningful health benefits and reductions in pregnancy complications.?Strong recommendation, moderate-quality evidence.
Physical activity should be accumulated over a minimum of 3 days per week; however, being active every day is encouraged.?Strong recommendation, moderate-quality evidence.
Pregnant women should incorporate a variety of aerobic and resistance training activities to achieve greater benefits. Adding yoga and/or gentle stretching may also be beneficial.?Strong recommendation, moderate-quality evidence.
Pelvic floor muscle training (PFMT) (eg, Kegel exercises) may be performed on a daily basis to reduce the risk of urinary incontinence. Instruction on the proper technique is recommended to obtain optimal benefits.?Weak recommendation, low-quality evidence.
Pregnant women who experience light-headedness, nausea or feel unwell when they exercise flat on their back should modify their exercise position to avoid the supine position.?Weak recommendation, very-low quality evidence.
Safety precautions for prenatal physical activity
Avoid physical activity in excessive heat, especially with high humidity.
Avoid activities which involves physical contact or danger of falling.
Avoid scuba diving.
Avoid physical activity at high altitude (>2500 m).
Maintain adequate nutrition and hydration. Drink water before, during and after physical activity.
Reasons to stop physical activity and consult a healthcare provider
Persistent excessive shortness of breath that does not resolve on rest.
Severe chest pain.
Regular and painful uterine contractions.
Vaginal bleeding.
Persistent loos of fluid from the vagina indicating rupture of the membranes.
Persistent dizziness or faintness that does not resolve on rest.
Heart rate ranges for pregnant women
Maternal age
Intensity
Heart rate range (beats/min)
<29
Light
102-124
?
Moderate
125-146
?
Vigorous
147-169
30+
Light
101-120
Moderate
121-141
Vigorous
142-162
Conclusion
It is important that these Guidelines be implemented into clinical practice to achieve the significant and potentially lifelong health benefits for both the mother and the child.
References
Michelle F Mottola et al. 2019 Canadian guidelines for physical activity throughout pregnancy. Br J Sports Med 2018.
A?study?by JAMA in 2019, showed the association between Push-up exercise capacity and future cardiovascular events among active adult men.
Cardiovascular disease (CVD) remains the leading cause of mortality worldwide. Robust evidence indicates an association of increased physical fitness with a lower risk of CVD events and improved longevity.
Findings:
This study of 1104 occupationally active adult men (mean age 39) found a significant negative association between baseline push-up capacity and incident cardiovascular disease risk across 10 years of follow-up.
Participants able to complete?more than 40 push-ups were associated with a significant reduction in incident cardiovascular disease event risk compared with those completing fewer than 10 push-ups.
Reference?Association between push-up exercise capacity and future cardiovascular events among active adult men ? Justin Yang et al. 2019, JAMA.
The shoulder is a ball (head of the humerus) and socket (glenoid cavity of the scapula) joint. There is a space between the acromion (which is part of the scapula) and the top surface of the humeral head, which is called the subacromial space (its height is 1-1.5 cm). This space is outlined by the acromion, coraco-acromial ligament and the coracoid process (which are parts of the scapula), which makes up the roof of the shoulder, and by the humeral head which makes up the floor of the shoulder. In this space are located tendons called the rotator cuff.
When the rotator cuff tendons, mainly the supraspinatus tendon, rubs against the roof of the shoulder repeatedly, at one point it will get inflamed and irritated, as a result it will cause pain. This is a common disorder of the shoulder, called?Subacromial Impingement Syndrome?(SAIS).
The?SAIS?can start suddenly or come on gradually. The symptoms are: pain in the top and outer side of your shoulder, which is worse when you lift your arm,?especially when you lift it above your head; pain or aching at night, which can affect your sleep; weakness in your arm.
Normally people with the?SAIS?try first the conservative treatment (nonsteroidal antiinflammatory drugs, physiotherapy, steroid injections, etc?) and if it doesn?t work they go for surgery,?Arthroscopic Subacromial Decompression?(ASD). The operation aims to increase the size of the subacromial area and reduce the pressure on the tendons. It involves cutting the coraco-acromial ligament and shaving away the bone spur on the acromion bone. This allows the tendons to heal.
Does arthroscopic subacromial decompression (ASD) really work?
A?study?carried out in 2018 assessed the efficacy of arthroscopic subacromial decompression (ASD) by comparing it with diagnostic arthroscopy (a placebo surgical intervention), and with a non-operative alternative, exercise therapy.
122 patients?with subacromial pain and unresponsive to conventional treatment; Age 35-65; Pain for 3 or more months.
Conclusions:?Arthroscopic subacromial decompression provided no benefit over diagnostic arthroscopy at 24 months in terms of pain and functional outcomes.
It is important to know that with the advent of arthroscopy, the number of subacromial decompression procedures has increased many times between the 1980s and the 2010s. A?study?reported that the incidence of anterior acromioplasty increased over time with the crude rate of 3.3 per 100,000 in 1980 to 1985 to 19.0 per 100,000 in 2000 to 2005 in the US. The overall incidence was higher in men than women, with the highest incidence in patients age 41 to 64 years.
Another?study??compared?ASD?with?conservative treatment?(physical therapy, exercise?programmes, NSAIDs,?and steroid injections) in adults with atraumatic shoulder pain for more than 3 months diagnosed as?subacromial pain syndrome?(SAPS), also labelled as rotator cuff disease.
Results: Surgery did not provide important improvements in pain, function, or quality of life compared with placebo surgery or other options (after 1 year). Frozen shoulder may be more common with surgery.
Practical issues with surgery:
After surgery, 2 weeks off work are typically needed;
Avoid heavy lifting for one to three weeks, overhead activities for 3 months.
References
Subacromial decompression versus diagnostic arthroscopy for shoulder impingement: randomised, placebo surgery controlled clinical trial ? BMJ 2018;
Arthroscopy and the dramatic increase in frequency of anterior acromioplasty from 1980 to 2005: an epidemiologic study ? 2010;
Subacromial decompression surgery for adults with shoulder pain: a clinical practice guideline ? BMJ 2019;
Osteoporosis is a disease that is characterized by low bone mass, deterioration of bone tissue, and disruption of bone microarchitecture: it can lead to compromised bone strength and an increase in the risk of fractures. Osteoporosis is a risk factor for fracture just as hypertension is for stroke.
It was estimated that the number of patients worldwide with osteoporotic hip fractures is more than 200 million. According to recent statistics from the International Osteoporosis Foundation, worldwide, 1 in 3 women over the age of 50 years and 1 in 5 men will experience osteoporotic fractures in their lifetime.
Osteoporosis has no clinical manifestations until there is a fracture. Fractures cause important morbidity; in men, in particular, they can cause mortality (article).
Fortunately, a well designed exercise program can help to counterbalance the losses in bone density that occur with age and may even allow people to slightly increase their bone density.
What is the best exercise to get my bones stronger?
The best exercises to improve your bone density are weight training and weight-bearing exercises (eg. walking, jogging, etc?). We need to feed our bones with load. When a bone is loaded, this activates the production of bone building cells (osteoblast), which are responsible for the synthesis and mineralization of bone.
Exercise to promote bone and muscle strength (link):
Muscle strengthening ? resistance exercise
Frequency: at least 2-3 times/week (non-consecutive days)
Duration: aim for 20-30 minutes on exercises that target legs, arms and spine
Intensity/Time: 1-3 sets of 8-12 repetitions of each exercise
Type: 1 exercise per body part
Weight bearing exercise with impact
The recommendations are:
For people with osteoporosis but without fractures: about 50 minutes?moderate impacts?on most days (jumps, skips, jogs, hops, etc.)
For people who have spinal fractures or are unable to do moderate impact: 20 minutes?lower impact?exercises on most days (walks, brisk walking, marching, stair climbing, etc.)
Balance exercise?is also recommended, up to 20 minutes per day. Balance needs to be challenged in order for it to be effective and balance exercises must be maintained as balance can decrease quickly.
What about cycling, and swimming?
These activities are not weight-bearing and don?t provide impact. They may strengthen muscles to some extent but because the weight of your body is held by the water or your bike, there isn?t much force going through to your bones. It?s probably not enough to promote bone strength.
What about walking?
Walking is a form of exercise such as cycling and swimming, and it doesn?t provide enough of a loading stimulus to stimulate bone growth.
Conclusions
With an aging population and longer life span, osteoporosis is increasingly becoming a global epidemic. Therefore, increasing awareness among healthcare workers, which, in turn, facilitates increase awareness of the normal populace, will be effective in preventing this epidemic (link).
References
An overview and management of osteoporosis ? Tumay et al., European Journal of Rheumatology ? 2016;
Magnetic resonance imaging (MRI) is commonly used to diagnose structural abnormalities in the shoulder. However, clinical findings may not be the source of symptoms (article).
In this study was evaluated over 100 individuals who reported unilateral shoulder pain, with no signs of adhesive capsulitis, no substantial range-of-motion deficit, no history of upper-limb fractures, no repeated shoulder dislocations, and no neck-related pain. All partecipants had MRI (interpreted by an orthopedic shoulder surgeon and a musculoskeletal radiologist) of both symptomatic and asymptomatic shoulders.
Results: Abnormal MRI findings were observed in both shoulders.
Rotator cuff tendinopathy, partial-thickness tear, full-thickness tear, labrum alterations, acromial morphology (Type I, II, III), long head of biceps alterations, AC joint alterations, subacromial fluid, fatty infiltration, glenohumeral osteoarthritis.
Only the frequencies of full-thickness supraspinatus tendon tears and glonohumeral osteoarthritis (OA) were higher (about 10%) in the symptomatic shoulder according to the surgeon?s findings only.
Agreement between the musculoskeletal radiologist and shoulder surgeon ranged from slight to moderate.
Conclusion
Most abnormal MRI findings were not different in frequency between symptomatic and asymptomatic shoulders.
Consider additional factors to help explain patients pain (Todd Hargrove).
Explain back pain is a great book written by David S. Butler and G. Lorimer Moseley in 2013. It is an evidence based book designed for therapists, patients and students. I have made some mind mapping about it. I hope you find it useful to review some concepts or study. For who don?t know, you have to read the mind map clockwise.?(Double check with Vanessa)
Knee arthroscopy versus conservative management in patients with
degenerative knee disease: a systematic review
Over the long term, patients who undergo knee arthroscopy versus those who receive conservative management strategies do not have important benefits in pain or function.
Patients and their healthcare providers must trade-off the marginal
short-term benefits against the burden of the surgical procedure (pain, swelling, limited mobility, restriction of activities, over a period of 2?6 weeks).
Raine Sihvonen et al. 2017,
Arthroscopic partial meniscectomy versus placebo surgery for a degenerative meniscus tear: a 2-year follow-up of the randomised controlled trial
Arthroscopic partial meniscectomy (APM) is one of the most common orthopaedic operations, with an incidence that has increased steadily from 1990s until late 2010s. Most APMs are carried out in middle-aged and older patients with knee symptoms and degenerative knee disease. Several recent meta-analyses based on randomised controlled trials (RCTs) have failed to show a treatment-benefit of APM over conservative treatment or placebo
surgery for these patients.
Conclusion:
In this 2-year follow-up of patients without knee osteoarthritis but with symptoms of a degenerative medial meniscus tear, the outcomes after APM were no better than those after placebo surgery. No evidence could be found to support the prevailing ideas that patients with presence of mechanical symptoms or certain meniscus tear characteristics or
those who have failed initial conservative treatment are more likely to benefit from APM.
Reed A C Siemieniuk, 2017,
Arthroscopic surgery for degenerative knee arthritis and meniscal tears: a clinical practice guideline
Approximately 25% of people older than 50 years experience knee pain from?degenerative knee disease.
What is degenerative knee disease?
Knee disease is an inclusive term, which many consider synonymous with osteoarthritis. We use the term degenerative knee disease to explicitly include patients with knee pain, particularly if they are >35 years old, with or without:
Imaging evidence of osteoarthritis (OA)
Meniscus tears
Locking, clicking, or other mechanical symptoms except persistent objective locked knee
Acute or subacute onset of symptoms
Most people with degenerative arthritis have at least one of these characteristics. The term degenerative knee disease does not include patients having recent debut of their symptoms after a major knee trauma with acute onset of joint swelling (such as haemarthrosis).
Management options?include weight loss if overweight, a variety of interventions led by physical therapists, exercise, oral or topical pain medications such as non-steroidal anti-inflammatory drugs, intraarticular corticosteroid and other injections, arthroscopic knee surgery, and knee replacement or osteotomy.
What you need to know
There is a strong recommendation against the use of arthroscopy in nearly all patients with degenerative knee disease, based on systematic reviews.?This recommendation applies to patients with or without imaging evidence of osteoarthritis, mechanical symptoms, or sudden symptom onset.
Arthroscopic knee surgery for degenerative knee disease is the most common orthopaedic procedure in countries with available data and on a global scale is performed more than two million times each year. Arthroscopic procedures for degenerative knee disease cost more than $3bn per year in the US alone.
We?re busting myths and reinforcing what the latest evidence says is best for your back.
Myth 1: Moving will make my back pain worse
Fact: Don?t fear twisting and bending, it?s essential to keep moving. Gradually increase how much you are doing, and stay on the go
Myth 2: I should avoid exercise, especially weight training
Fact: Back pain shouldn?t stop you enjoying exercise or regular activities. In fact, studies found that continuing with these can help you get better sooner,? including using weights where appropriate.
Myth 3: A scan will show me exactly what is wrong
Fact: Sometimes it will, but most often it won?t. Also, even people without back pain have changes in their spine so scans can cause fear that influences behaviour, making the problem worse.
Myth 4: Pain equals damage
Fact: This was the established view but more recent research has changed our thinking. Modern physiotherapy takes a holistic approach that helps people understand why they are in pain.
We have to fight the fear and move more!!!
Problem is these myths create fear, which causes people to stop doing many of the activities they need to do to address the problem. So let?s bust those myths and reinforce what the latest evidence says is best for your back.
Physiotherapists are the experts in treating and preventing back pain.
Sciatica (also called radicular pain) is commonly used to describe radiating leg pain. It is caused by inflammation or compression of the lumbosacral nerve roots (L4-S1) forming the sciatic nerve. Sciatica can cause severe discomfort and functional limitation.
People with sciatica usually describe aching and a sharp leg pain radiating below the knee and into the foot and toes. The pain can have a sudden or slow onset and varies in severity. Most people report coexisting low back pain. Disc herniations affecting the L5 or S1 nerve root are more common and cause pain at the back or side of the leg and into the foot and toes. If L4 root is affected, pain is localised to the front and lateral side of the thigh. Tingling or numbness and loss of muscle strength in the same leg are other symptoms that suggest nerve root involvement.
How common is sciatica?
In the UK about 60% of patients with back and leg pain were clinically diagnosed with sciatica.
How is sciatica diagnosed?
Sciatica is a clinical diagnosis based on the person?s symptoms and findings on examination. Symptoms and signs suggesting sciatica:
Unilateral leg pain more severe than low back pain;
Pain most commonly radiating posteriorly at the leg and below the knee;
Numbness and/or paraesthesia in the involved lower leg;
Neurological deficit associated with the involved nerve root (muscle weakness/absence of tendon reflexes/sensory deficit);
Positive neural tension test with provocation of pain in the affected leg (straight leg raise test/femoral nerve test/slump test).
Role of imaging
Routine imaging is not advised in people with non-specific low back pain with or without sciatica
Disc herniation is a common age related finding
Consider imaging if symptoms progress for more than 12 weeks, or if the person has progressive neurological deficits (signs of urinary retention or decreased anal sphincter tone ) or worsening pain
Conservative treatment
Encourage patients to remain active and avoid bed rest
What is the prognosis?
Most people experience an improvement in symptoms over time with either conservative treatment or surgery
For disabling symptoms lasting longer than 6 weeks with a lack of response to non-operative management, specialist referral (rheumatologist, rehabilitation physician, spinal surgeon) can also be considered
Laminectomy surgery for radiculopathy may shorten the duration of symptoms, but outcomes at 12 months are similar to non-operative treatment and surgery is associated with increased risk of further surgery
Decompression surgery for central lumbar canal stenosis may improve symptoms, but there is a lack of high -quality evidence for its superiority over non-operative management
Globally people are becoming less active, this is partly due to a busy life style. We have become reliant on our cars, using these for even the shortest of distances. Due to changing times and covid-19 many people are now working from home, meaning even less activities and exercises. Due to advanced technology, fast food and shopping can be done without living the house again reducing activities.
The World Health Organization (WHO) in 2010 identified?physical inactivity?as the fourth leading risk factor for global mortality (6% of deaths globally).
This follows high blood pressure (13%), tobacco use (9%) and high blood glucose (6%). Overweight and obesity are responsible for 5% of global mortality.
Insufficient physical activity is a key risk factor for noncommunicable diseases (NCDs) such as cardiovascular diseases, cancer and diabetes.
Physical activity has significant health benefits and contributes to prevent NCDs.
Globally, 1 in 4 adults is not active enough.
More than 80% of the world?s adolescent population is insufficiently physically active.
How much of physical activity is recommended (for adults aged 18-64 years)?
Should do at least 150 minutes of moderate-intensity physical activity throughout the week, or do at least 75 minutes of vigorous-intensity physical activity throughout the week, or an equivalent combination of moderate- and vigorous-intensity activity.
For additional health benefits, adults should increase their moderate-intensity physical activity to 300 minutes per week, or equivalent.
Muscle-strengthening activities should be done involving major muscle groups on 2 or more days a week.
Moderate aerobic activity: walking, riding a bike, dancing, hiking, doubles tennis, water aerobics, rollerblading.
Vigorous activity: jogging or running, swimming fast, riding a bike fast or on hills, sports (football, rugby, netball, hockey,?), aerobics, gymnastics, martial arts.
In general, 75 minutes of vigorous intensity activity can give similar health benefits to 150 minutes of moderate intensity activity.
It is important to know that vigorous intensity activity increases our?cardiorespiratory fitness?which allows us to live longer .
Cardiorespiratory fitness is an indication of a person?s overall physical health, and improving it should be the aim of everyone because it helps us to live better and more than anything longer.
A?study?pubblished in 2018 by Jama, compares cardiorespiratory fitness long-term with mortality. The take aways from this study are:
Cardiorespiratory fitness is inversely associated with long-term mortality.
High aerobic fitness is associated with the greatest survival and is associated with benefit in older patients and those with hypertension.
Cardiorespiratory fitness is a modifiable indicator of long-term mortality, and health care professionals should encourage patients to achieve and maintain high levels of fitness.
Think how to link push ? ups in the blog
Get better at Push-Ups (Justin Yang et al. 2019, JAMA)?
This study showed the association between Push-up exercise capacity
and future cardiovascular events among active adult men.
Cardiovascular disease (CVD) remains the leading cause of mortality worldwide. Robust evidence indicates an association of increased physical fitness with a lower risk of CVD events and improved longevity.
Findings:
This study of 1104 occupationally active adult men (mean age 39) found a significant negative association between baseline push-up capacity and incident cardiovascular disease risk across 10 years of follow-up.
Participants able to complete more than 40 push-ups were associated with a significant reduction in incident cardiovascular disease event risk compared with those completing fewer than 10 push-ups.
References
The World Health Organization (WHO), Physical Activity ? 2010;
Association of cardiorespiratory fitness with long-term mortality among adults undergoing exercise treadmill testing, JAMA 2018.
A?study?published by the Lancet in 2018, reported that almost everyone will have low back pain at some point in their lives. It can affect anyone at any age, with the biggest increase seen in low-income and middle-income countries. Disability due to back pain has risen by more than 50% between 1990 and 2015.
For nearly all people with low back pain, it is not possible to identify a specific cause (non-specific low back pain). Only a small proportion of people have a well understood pathological cause ? eg, a vertebral fracture, malignancy, or infection (specific low back pain).
Key messages:
Low back pain is an extremely common symptom.
Most episodes of low back pain are short-lasting with little or no consequence
People with physically demanding jobs, physical and mental comorbidities, smokers, and obese individuals are at greatest risk of reporting low back pain.
Disabling low back pain is over-represented among people with low socioeconomic status, where possibilities for job modification are limited.
Lifestyle factors, such as smoking, obesity, and low levels of physical activity, that relate to poorer general health, are also associated with occurrence of low back pain episodes.
Prevention and Treatment of low back pain
There is lack of evidence for prevention of low back pain: back belt, ergonomic furniture, work-place education, no-lift policies, mattresses, lifting device. The only known effective interventions (based on low to moderate quality evidence) are exercise combined with education, or exercise alone.
Do not recommend passive electrical or physical modalities, such as ultrasound, transcutaneous electrical nerve stimulation (TENS), traction, short-wave diathermy, and back support for low back pain.
No one exercise seems superior to another.
Some guidelines do not recommend passive therapies, such as spinal manipulation or mobilisation, massage, and acupuncture, some consider them optional, and others suggest a short course for patients who do not respond to other treatment.
Interventional therapies (e.g. injections, surgery and medicines) have a limited role for non-specific low back pain.
Non-pharmacological treatments in the form of advice, reassurance, and activity should be the first line treatmen option for non-specific low back pain.
Paracetamol is not recommended.
Consider oral non-steroidal anti-inflammatory drugs (NSAIDs), taking into account potential risks, and if using them, prescribe the lowest effective dose for the shortest possible time.
Routine use of opioids is not recommended, since benefits are small and substantial risks exist, including overdose and addiction. If used, they should only be in carefully selected patients, for a short duration, and with appropriate monitoring.
References
Low Back Pain: a major global challenge, The Lancet, 2018;
Osteoarthritis (OA) is the most common form of arthritis, affecting an estimated 302 million people worldwide, and is a leading cause of disability among older adults. The knees, and hips, are the most commonly affected joints. OA leads to pain, stiffness, swelling, and loss of normal joint function (article).
Recommendations for physical, psychosocial, and mind-body approaches for the management of osteoarthritis of the knee, and hip.
Strongly recommended: Exercise, Weight loss, Tai Chi, Knee brace (tibiofemoral knee brace), Cane, Self-efficacy and self-management programs.
Conditionally recommended: Yoga (for the knee), Cognitive Behavioral Therapy, Balance Training, Patellofemoral Braces, Acupuncture, Thermal Interventions, Kinesiotaping (for the knee).
Conditionally recommeded agaist: Modified Shoes, Wedged Insoles, Massage, Manual Therapy with / without exercise, Pulsed Vibration Therapy
Knee X-ray and Pain
Radiographs have long been considered as the reference standard for the assessment of OA, for more than four decades. To date, the majority of studies have reported that radiographic OA (ROA) is poorly correlated with knee symptoms, and most risk factors for ROA are not strong predictors of knee pain. Pain perception is complex, however, and knee pain is frequently associated with non-OA variables, such as psychosocial factors, education, economic status as well as local pathology (article).
Knee MRI and cartilage damage
Arthritic change within knee joints is very common even in those without pain, for example a study from?Geurmazi et al. 2012, found 69% of people with no pain had evidence of cartilage damage on MRI.
Running does not increase symptoms or structural progression in people with knee osteoarthritis? ??Grace H. et al. 2018
Key points from the article:
Running doesn?t appear to increase the risk of developing hip or knee arthritis;
Running with knee OA doesn?t seem to speed up disease progression or worsen symptoms over a period of time.
Prescribed Exercise For Knee Osteoarthritis Via Skype????HINMAN et al. 2017
Key points from the article:
Telerehabilitation via Skype was feasible for patients with knee osteoarthritis, primarily due to familiarity with the technology and the convenience of having physical therapy consultations within the home;
Patients and physical therapists found this service delivery model was empowering for patients and that positive therapeutic relationships were developed, contributing to high levels of patient satisfaction with care provided.
References
2019 American College of Rheumatology/Arthritis Foundation Guideline for the Management of Osteoarthritis of the Hand, Hip, and Knee;
Radiographic Knee Osteoarthritisand Knee Pain: Cross-sectionalstudy from Five Diferent Racial/Ethnic Populations 2018;
Running does not increase symptoms or structural progression in people with knee osteoarthritis: data from the osteoarthritis initiative. Clin Rheumatol. 2018;
Prevalence of abnormalities in knees detected by MRI in adults without knee osteoarthritis: population based observational study (Framingham Osteoarthritis Study), Guermazi et al. 2012;
?Sounds a bit crazy, but it was almost more personal:? a qualitative study of patient and clinician experiences of physical therapist- prescribed exercise for knee osteoarthritis via Skype, Hinman et al 2017.
