INJURY PREVENTION IS IMPORTANT FOR RESULTS
Success in sport is dependent on a number of factors (eg, skill, fitness, squad size, tactics, and psychological factors). Athlete durability is also a key component of success.
In team sports, research shows a strong link between player availability and the success of the team, and that injuries and illness are the most common reasons for athlete unavailability in training and matches (REF). Research in team sports demonstrates an inverse relationship between injury burden and success of the team. Lower player availability is associated with failure to achieve key performance indicators. Injuries detrimentally affect the final ranking position in team sports (REF). And, research from professional European football shows lower season injury rates results in more successful seasons (REF).
Injuries and illnesses also affect success in individual sports. In elite track and field athletics, injuries and illness and their influence on training availability during preparation are major determinants of an athlete's chance of performance goal success or failure. Research shows the likelihood of achieving a performance goal increases by 7-times in athletes who complete >80% of planned training weeks. And, training availability accounts for 86% of successful seasons (REF).
So, injuries can determine success of failure in team and individual sports. Therefore, injury prevention strategies should be a focus for success-driven athletes and teams.
INJURY PREVENTION PROGRAMS
A number of sporting bodies have developed standardised injury prevention programs that are very effective at reducing injury rates. Sports that include these programs into their training have been shown to have between 50-80 per cent fewer injuries. These injury prevention programs are a series of exercises that are reasonably quick and easy to perform as part of a warm up. They include plyometric (jumping and landing), neuromuscular control (challenging balance, agility, addressing poor movement patterns), and strength exercises.
For every 1,000 hours of game play, elite football players suffer between 12 – 35 injuries (REF). The most common types of injury sustained during a football game are muscle strains, ligament sprains, and contusions. Ankle, knee, and groin have the highest incidence of injury, and the greatest risk for sustaining an injury is during a football game as opposed to during a training session (REF).
The warm-up program “FIFA11+” is an injury prevention program designed by the Federation Internationale Football Association (FIFA) Medical and Research Centre (F-MARC) in 2006. It was designed to reduce the occurrence of injuries associated with playing football.
The FIFA11+ consists of three parts and 15 exercises in total:
The FIFA11+ program has been studied extensively over the last ten years to determine its effectiveness on injury prevention and physical performance measures, across a variety of populations. The FIFA11+ program has been shown to significantly reduce the risk of injuries in football (REF). This includes a 77% decrease in ACL injuries (REF), a 48% reduction in lower limb injuries (REF), and an overall injury reduction of 35% per 1000 hours (REF).
FIFA 11+ and more resources for injury prevention in football are available here: footballnsw.com.au/protection-and-safety/injury-prevention/
Netball Australia has developed the "KNEE Program” to help prevent knee and other lower limb injuries in netball.
Knee and ankle injuries are common in netball, making up three quarters of all injuries. Devastating ACL injuries are unfortunately common in netball, making up 25% of the serious injuries.
The KNEE program offers a range of warm-up exercises that help prevent injury. There are a range of age and experience appropriate exercises for junior, through to elite netballers. They are easily understood by players and coaches, with a number of options offering variability and progression.
It would be great for the KNEE program to be widely adopted by Australia's largest participation sport for females.
KNEE Program resources are available at: https://knee.netball.com.au
AUSTRALIAN RULES FOOTBALL
FootyFirst is a five level progressive exercise training program that has been developed specifically to reduce the risk of common leg injuries in community Australian rules football.
FootyFirst begins with a warm-up, followed by leg strengthening and conditioning exercises, and training to improve balance, landing and side-stepping skills. It requires only standard training equipment and can replace the traditional warm-up. Once players and coaches are familiar with the exercises, the warm-up should take about 5 minutes, and the strength and conditioning exercises and jumping, landing and changing direction activities about 15 minutes.
Performed correctly and frequently, FootyFirst will improve performance and reduce injury risk. FootyFirst has been shown to decrease knee injuries by 50% and all leg injuries by 22% (REF). It will improve players’ leg strength and control – from their hip to hamstring, groin to thigh, lower leg, knee, ankle and foot.
Resources include the FootyFirst Coaches’ Manual, a series of posters illustrating the exercises at each level, and the FootyFirst Coaches DVD is available at: aflcommunityclub.com.au/index.php?id=906
PT Inquest, my favourite physio podcast, recently discussed this paper:
Misconceptions and the Acceptance of Evidence-based Nonsurgical Interventions for Knee Osteoarthritis. A Qualitative Study
The abstract summarises:
In contrast to best practice guidelines for knee osteoarthritis (OA), findings from several different healthcare settings have identified that nonsurgical treatments are underused and Total Knee Replacement surgery is overused. Empirical evidence and qualitative observations suggest that patients’ willingness to accept nonsurgical interventions for knee OA is low.
Participants’ beliefs about knee OA and its treatment were identified. Beliefs were grouped into five belief dimensions:
The participants' beliefs are what I would guess, based on what I hear from patients everyday:
The authors conclude:
Common misconceptions about knee OA appear to influence patients’ acceptance of nonsurgical, evidence-based treatments such as exercise and weight loss.
Once the participants in this study had been “diagnosed” with “bone-on-bone” changes, many disregarded exercise-based interventions which they believed would damage their joint, in favor of alternative and experimental treatments, which they believed would regenerate lost knee cartilage.
These misconceptions do feel like commonsense and, as such, are widely held by the general public. Some of them may be true at the very end stage of osteoarthritic disease, but they are definitely not true for all patients with osteoarthritis, and as such, the misconceptions are harmful because patients disregard beneficial conservative treatments like weight loss and exercise, and rush towards surgical options.
"BONE ON BONE" is a metaphor that is commonly used, even by physios and knee surgeons.
"Bone on bone" creates a very dramatic image of what's going on in the knee, and undermines the possibility of osteoarthritis being pain free. Using words like "bone on bone" can cause harm because it sounds like it is definitive and painful, when in reality it's only a metaphor.
The reality could be explained more like: "the joint reinforces and repairs the damaged area by laying down new tissue". Or, "the joint wants to make itself even stronger than cartilage, so it lays down stronger building blocks - bone cells".
Not everyone with osteoarthritis has "bone on bone", and the perception of "bone on bone" as what's happening in the knee can make patients less likely to stick with evidence-based conservative treatment options.
The concept of "WEAR AND TEAR" makes sense if you imagine the joint as mechanical. A cupboard's metal hinge can be opened and closed a certain number of cycles before it breaks. Metal and plastic fatigues and fails. Mechanical joints "wear out". But our joints aren't made of metal and plastic. Knees are not mechanical joints. They are biologically active joints, that adapt to what we do.
If we do a million bicep curls, we don't expect our biceps to "wear out" - we expect to end up with bigger, stronger biceps. Similarly, the bones, cartilage, ligaments and muscles in our knees are biologically adaptive, they have regenerative ability, and adapt to what we do. Our joints get stronger with use.
Rather than "wear and tear", the more appropriate phrase should be: "use it or lose it".
DOESN'T RUNNING "WEAR OUT" KNEES?
Another common misconception is that running "wears out" knees.
Doctors and knee surgeons see patients complaining they have sore knees when they run. The X-ray shows some arthritis, so it's very easy to make the assumption that running causes arthritis. But we know that distance runners don't "wear out" their knees. Runners have better knees than non-runners.
This 2017 research comparing 2,637 runners to non-runners (matched for age, weight, mileage, injury, and other variables) concludes: There is no increased risk of symptomatic knee OA among runners compared with non-runners. In those without OA, running is not detrimental to the knees.
This 2008 research concludes: Long-distance running among healthy older individuals was not associated with accelerated radiographic OA, and long-distance running or other routine vigorous activities should not be discouraged among healthy older adults out of concern for progression of knee OA.
This 2004 research concludes: The results of this literature review strongly suggest that regular mild-moderate impact exercise does not increase the risk of OA, and that there is some evidence that it does not increase symptoms in patients with mild-moderate OA. And: Regular running increases joint space width.
"Including the Nordic hamstring exercise in injury prevention programmes halves the rate of hamstring injuries: a systematic review and meta-analysis of 8459 athletes."
(Nicol van Dyk, Fearghal P Behan, Rod Whiteley, British Journal of Sports Medicine. Published Online First: 26 February 2019. doi: 10.1136/bjsports-2018-100045)
Research question Does the Nordic hamstring exercise (NHE) prevent hamstring injuries when included as part of an injury prevention intervention?
Design Systematic review and meta-analysis.
Eligibility criteria for selecting studies We considered the population to be any athletes participating in any sporting activity, the intervention to be the NHE, the comparison to be usual training or other prevention programmes, which did not include the NHE, and the outcome to be the incidence or rate of hamstring injuries.
Analysis The effect of including the NHE in injury prevention programmes compared with controls on hamstring injuries was assessed in 15 studies that reported the incidence across different sports and age groups in both women and men.
Results There is a reduction in the overall injury risk ratio of 0.49 (95% CI 0.32 to 0.74, p=0.0008) in favour of programmes including the NHE. Secondary analyses when pooling the eight randomised control studies demonstrated a small increase in the overall injury risk ratio 0.52 (95% CI 0.32 to 0.85, p=0.0008), still in favour of the NHE. Additionally, when studies with a high risk of bias were removed (n=8), there is an increase of 0.06 in the risk ratio to 0.55 (95% CI 0.34 to 0.89, p=0.006).
CONCLUSIONS: Programmes that include the NHE reduce hamstring injuries by up to 51%. The NHE essentially halves the rate of hamstring injuries across multiple sports in different athletes.
IS IT BAD TO HAVE "STIFF" MUSCLES?
Stiff muscles are a counterintuitive superpower of NBA athletesPhilip Anloague, University of Dayton
For most people, the term “stiffness” has negative connotations. When you wake up in the morning complaining of a “stiff back,” the remedy might include taking a hot shower, doing some yoga, swallowing aspirin, or visiting a physical therapist to loosen up. Stiffness is typically viewed as unpleasant and can limit one’s physical activities.
Surprisingly, though, for elite athletes like professional basketball players, muscle stiffness is not only something that is necessary, you could say it’s their superpower. As a physical therapist and researcher who works with National Basketball Association players, I’m interested in understanding the key factors that help to minimize injury risk and maximize performance in elite athletes – and understanding stiffness is an important part of that.
Spring in your step
Physiologists think of muscles as being like biomechanical springs. Muscles contract to produce forces that help you move and stretch to allow enough range of movement. Stiffness is a way to talk about how springy a muscle is. It is a characteristic of how much it can lengthen in response to an applied force. The spring of a muscle allows it not only to stretch but also to recoil during muscle contraction. This process allows for movements including walking, running and jumping.
The force required to deform or stretch a muscle is correlated to a degree of spring or stiffness and to the extent the muscle is lengthened. Strength is important, but stiffness can help an athlete generate even more power.
Basketball is a vertical sport that includes up to 46 jumping and landing activities for an individual player per game. That’s 2 to 4 times more jumping than in soccer or volleyball. It’s also a multi-directional sport – an average player changes direction or activity every 2 to 3 seconds, requiring constant acceleration and deceleration of movements.
Lower extremity stiffness is important for optimal basketball performance because athletes who appropriately use greater stiffness characteristics can take advantage of the elastic energy it creates. A muscle can only stretch so far because its length is limited by its degree of stiffness. So, like a spring or a rubber band, when the muscle is stretched, that stiffness helps to create elastic energy that can then be used with a muscle contraction to help you run or jump on the court.
This helps someone like Russell Westbrook leap in the air, stop on a dime, then accelerate down court during a fast break. It takes him just 3.36 seconds to run from baseline to baseline.
The sweet spot
However, there is a point of diminishing returns. Too much muscle stiffness can lead to reduced joint motion and a decreased ability to absorb shock at the joints. This can place one at greater risk for stress fractures or even osteoarthritis, the wear and tear of cartilage that can cause joint pain. Evidence suggests that too much stiffness may lead to injury.
And on the other side of the spectrum, a player needs a certain degree of flexibility and joint mobility to support the proper elongation of muscle and tendons that allow for the appropriate range of motion.
So players need to balance these extremes, landing in the sweet spot of optimal lower extremity stiffness: not too much, which can lead to high levels of force and loading rates and a greater risk for bony injuries. And not too little, which is associated with an increased risk for soft tissue injury and muscle strains.
My research team is investigating these relationships in an attempt to help elite athletes minimize risk of injury and maximize performance. The first step is in understanding what “normal” clinical measurements are for elite athletes.
Textbook values have been established for the general population but this information is lacking for NBA players. For example, a typical value of ankle flexibility for the average individual is about 50 to 55 degrees. Our research team has found that the typical NBA player is more stiff and averages 35 degrees.
When comparing elite basketball players to textbook norms it might appear that they are too tight and even dysfunctional. However, to be successful in their sport, this degree of stiffness is actually their superpower. If trainers start stretching Lebron James’ muscles to match the textbook values of the general population, he may start jumping like the general population. That tactic could very well be kryptonite to an NBA athlete.
Training to minimize injury and maximize performance
Physical therapists know that the so-called fast twitch muscle fibers – the ones responsible for jumping and sprinting – have a higher propensity for stiffness. With training the level of stiffness can be increased to improve performance.
Evidence suggests that plyometric and bounding exercises that involve jumps, hops, or bounds, performed in a stretch shortened cycle do have a positive effect in the ability for muscle to have more spring. But overall, your own degree of stiffness versus springiness is a combination of nature and nurture, genetics and training.
Research related to better understanding the continuum between stiffness and compliance can help physical therapists and trainers when working with basketball players. They need to know dosage – how much to stretch or strengthen. Work is underway that contributes to this endeavor. There are also initiatives that aim to understand player load and the cumulative physical demands that elite athletes undergo when generating fast and powerful movements. Researchers also need to understand what the best methods and technologies are for monitoring these loads. My colleagues and I theorize that there is an optimal level of compliance and stiffness that helps keep our basketball heroes super.
Osteoarthritis (OA) is a leading and increasing cause of disability and has a significant impact on health-related quality of life. Osteoarthritis is a structural change to the cartilage and boney surfaces in a synovial joint. Most of the joints in our skeletal system are synovial joints, which is where two opposing bones articulate in a joint capsule filled with synovial fluid. The synovial fluid is a lubricant to help the joint move, as well as a source of nutrition for the cartilage that lines the joint surfaces. The articulating surfaces in synovial joints are lined with articular cartilage, which is a smooth, glossy surface to decrease the friction in the joint (as opposed to fibrous cartilage, which is the rubbery type cartilage that plays a more structural role, found in the meniscus in knees and the rubbery part of your ribs, nose, and ears).
The fleshy parts of muscles and organs is pink because it is full of blood, which brings oxygen and nutrition, and is important for healing damage. Cartilage looks white because it doesn’t have a blood supply, so articular cartilage relies of the synovial fluid for its nutrition. This isn’t as effective as a blood supply, so when cartilage is damaged it doesn’t heal well. Nanna damages the cartilage in her knees and it never really repairs.
Once articular cartilage is damaged, the joint tries to reinforce and repair the damaged area by laying down new tissue. It would be great if cartilage repaired itself with new cartilage cells, but what happens is the joint wants to make itself even stronger than the obviously insufficient cartilage, so it lays down a stronger building block - bone cells. So when we say that Nanna has “worn away” her knee to the point where it’s “bone on bone”, it’s not just that she’s warn away the cartilage, but actually there’s also a build up of “extra” bone, as the knee tries to make itself stronger than cartilage. Rather than being a nice smooth, glossy surface, the extra bone is now a bit rough, so we can hear and feel some gravely crunching and creaking in an osteoarthritic joint.
Osteoarthritis occurs most frequently in the knees, hips, hands, and spine and is more common the older we get. Osteoarthritis is diagnosed with an X-ray that shows the changes to the bony profile in the joint.
When we look at what causes osteoarthritis:
Osteoarthritis isn't painful most of the time. At a certain age, essentially everyone will have arthritic changes in their joints without knowing about it. When we X-ray the joint, it doesn’t look as good as it used to, but it doesn’t hurt. It’s a bit like my grey hair and wrinkles - they don’t look great anymore, and it's a sign that I’m getting older, but I don’t expect them to be painful.
If an arthritic joint is painful, it tends to go through phases of being sore and not being sore at all. It can be sore for a day, a week, a month, or a year, but then will be fine again. Whether or not it is sore is not determined by the severity of the changes we see on the X-ray. We can see nasty looking joints that have never been sore, and we see very sore joints that look fine on the X-ray. There isn’t much of a correlation.
What determines whether or not the osteoarthritis hurts is the body’s perception of "vulnerability" in that joint - essentially whether or not it feels strong or weak. Pain is an alarm system “software”, employed to defend against damage to the "hardware”. We can have different levels of sensitivity of how easily the alarm is triggered. Very commonly, an arthritic joint starts to hurt more after a period of rest, as the body looses some fitness, muscles loose some strength, an arthritic joint gets less support from the external scaffolding of the muscles, it feels more vulnerable, and communicates that by being painful, as a way of saying “be careful”.
So that gives us some treatment options for arthritis:
WEIGHT LOSS (Adipose)
How do you decide when it’s time to have a joint replacement?
I suggest it’s time when you really can’t walk anymore because of the pain, and/or the pain is stopping you sleeping at night. Joint replacements last for about 25 years on average, so don’t rush into doing it too early. The rehab after surgery is 3-12 months before the leg completely feels like it’s yours. The joint replacements are good for relieving pain, but unfortunately we don’t see improvements in patients’ activity levels after surgery. Total hip replacements are easier all around than total knee replacements.
Do you have Osteoarthritis?
A recently published article by Haroy et al, in the British Journal of Sports Medicine, described a simple exercise routine that decreased the number of groin injuries in male footballers by 41%.
Groin injuries are very common in football. Research shows that weaker groin muscles are associated with an increased risk of groin muscle injury. So strengthening groin muscles can potentially prevent injury.
The paper studied the Copenhagen Adduction exercise, which has previously been shown to strongly recruit adductor longus.
Haroy et al, offered the Copenhagen at three levels of resistance, based of the players’ pain. Players started with Level 3. If the exercise gave them more than 3/10 pain, they were instructed to do the exercise level below instead: 3 > 2 > 1.
The training protocol is shown in the following table:
Being only one, quick exercise, compliance was high. They found performing the Copenhagens decreased the risk of groin injury by 41%.
The full article is HERE.
Copenhagens are definitely worth adding to your training. The concept is similar to strengthening hamstrings with the Nordic Hamstring Curl which has been shown to prevent 70%-85% of hamstring strain injuries.
The current approach to musculoskeletal pain is failing
The majority of persistent non-traumatic musculoskeletal pain disorders do not have a pathoanatomical diagnosis that adequately explains the individual’s pain experience and disability. We contend this has resulted in two concerning developments in the management of people with such disorders. First, structural changes observed on imaging that are highly prevalent in pain free populations, such as rotator cuff tears, intervertebral disc degeneration, labral tears and cartilage changes, are ascribed to individuals as a diagnosis for their condition. In this context, this information may result in the individual believing that their body is damaged, fragile and in need of protection, resulting in a cascade of movement and activity avoidance behaviours and seeking interventions to correct the structural deficits.1 This trend has led to exponential increases in elective surgery rates and associated costs, while the efficacy of repairing (eg, rotator cuff and medical meniscal tears), reshaping (eg, subacromial decompression) or replacing (eg, lumbar intervertebral discs) the structures considered to be at fault has been substantially challenged.2–10Second, it is arguable that musculoskeletal clinicians have invented treatments for conditions that may not exist or be readily detected (such as trigger points, sacral torsions), and they have developed and perpetuated treatment paradigms (such as ‘correcting’ upper body posture and muscle imbalances) that do not conform to current research evidence.11–14 These two trends have created an expectation that interventions (frequently ‘passive’) will provide a ’cure’, and typically quickly, with minimal self-contribution. This expectation may have been derived from a conversation with a friend or family member, from the Internet or from an advertising campaign, but almost certainly originated from health professionals.
Body in Mind blog post: https://goo.gl/qzpQJJ
For at least two decades, we have known that for chronic pain conditions there is discrepancy between tissue damage seen on clinical imaging and clinical presentation. You can have a severely osteoarthritic X-ray with no pain, or a completely normal X-ray with severe pain. Despite this disparity, imaging findings, such as meniscal tears, rotator cuff tears and degenerative discs are often interpreted as causes of pain, triggering medical and surgical interventions. But given the disconnect with actual symptoms, it is perhaps not surprising that interventions to remove/fix the tissue or targeting tissue regeneration, such as arthroscopy, stem cells or platelet rich plasma, are often no more effective in reducing symptoms than sham treatments .
In light of growing concern of overdiagnosis, our recent systematic review and meta-analysis of 63 studies of 5,397 completely asymptomatic uninjured knees revealed that knee osteoarthritis features assessed on MRI (cartilage defects, meniscal tears and osteophytes) were common (up to 60% in those aged >60 years) . Their prevalence, instead of being associated with pain, was closely linked to age. A majority of these features, when assessed clinically, should be viewed like wrinkles on the skin – a normal part of aging that don’t typically require ‘fixing’.
One might theorise the reverse relationship, that even if osteoarthritis presence doesn’t predict pain, pain presence might predict progression of osteoarthritis. Surprisingly, that theory was also refuted in our recent longitudinal study that followed up patients with imaging 15 and 20 years post-anterior cruciate ligament reconstruction . Neither the presence, nor persistence, of patellofemoral pain in the years post-operatively predicted any significant difference in patellofemoral osteoarthritis 15-20 years later.
Pain and related disability are normally the primary concern for patients seeking treatment. The persistence of pain experience in response to mechanical stimuli is often thought to indicate adverse tissue loads from a biological perspective, leading to interventions aimed at tissue ‘offloading’ to prevent injury or degeneration. Counterintuitively, offloading tissues in the context of musculoskeletal pain may be more problematic than beneficial for tissue health. For example, following acute knee injury, which places young adults at high risk of early-onset knee osteoarthritis, those who actually developed osteoarthritis walked with lower peak knee contact forces (2.10 x body weight) than those who didn’t develop osteoarthritis (2.89 x body weight) .
Furthermore, one-third of adolescents who develop patellofemoral pain are sedentary . In addition to the potential for mechanotherapy (ie. promotion of tissue repair/remodelling with exercise-therapy) , tissue loading through exercise can also have acute sensory effects – improving pain by reducing a sensitised nervous system through a reduction in cortical inhibition . It is important to remember that clinical changes occur beyond the resolution of imaging and/or tissue mechanical properties.
Pain can persist with safe tissue loads. Even when persistent pain displays ‘mechanical’ behaviour, this could represent the early or unnecessary warnings from a sensitised nervous system, as much or more than any threat to tissues. For example, patellofemoral pain, often considered mechanical in origin with greater pain in activities that apply greater load to the knee, is characterised by local and widespread hyperalgesia indicating a combination of peripheral and central mechanisms driving pain . Approaches to pain management therefore need to consider more than just mechanical effects of altering tissue load, because positive adaptations knock-on to affect other domains. Exercises with gradual progression of loads, intended for mechanotherapy can also be viewed as neurosensory-therapy (modulating sensitisation and motor control) as well behavioural therapy (modulating thoughts and feelings related to body use).
Pain should not typically be a barrier for tissue and joint loading, but it is an important clinical consideration when planning how much load will provoke a sensitised nervous system. For example, for patients with chronic knee and hip pain, a program of progressive loading (strengthening) resulted in sensory adaptations leading to a considerable decrease in exercise-induced pain flares . Even in acute injury settings, where traditional first-line injury management was rest (the R in RICE), guidelines have now shifted and advocate ‘protect and optimally load’ (the POL in POLICE) .
There is need for vigilance but not fear of gradual progressive loading interventions for people with persistent musculoskeletal pain. The potential acute benefits for the sensory nervous system, the long-term benefits on tissue mechanical properties and minimising degeneration, as well as the general health benefits are all valuable. Even in the presence of persistent musculoskeletal pain, gradual progression of tissue loading through exercise is likely to be more friend than foe.
ORIGINAL ARTICLE HERE: https://goo.gl/DdPtah
Exercise and movement may be the best medicine for back pain.
You might be considering surgery or other intervention to treat your back pain. But less may actually be more for this common problem, and in many instances the best medicine is good old-fashioned movement and exercise.
The enigma of back pain
Back pain is one of the most common medical problems in the United States, according to the National Institutes of Health. It's also a little strange as far as ailments go.
When you twist your ankle, you generally have pain that slowly goes away as the injury heals. Not so with back pain. Relief doesn't seem to be linked to healing because the pain is usually unrelated to an injury. In fact, back pain often diminishes over time, even when there is an underlying problem like a herniated disc or arthritis, says Dr. James Rainville, assistant professor of physical medicine and rehabilitation at Harvard Medical School.
Adding to the mysteries of back pain is the fact that people tend to report more back pain in their 40s and 50s than they do as they get older. But back degeneration generally increases over time, so logically, people should have more pain — not less — as they age.
In addition, as many as 80% of adults report at least one episode of back pain. The other 20% never experience back pain at all. But it's not because their spines are normal. Imaging tests on these pain-free folks show as much degeneration in their lower spine as everyone else has, says Dr. Rainville. The question is, why don't these changes seen on imaging cause them pain?
The oddities of back pain are likely due to the fact that a neurological healing process — not a physical one — is at work, says Dr. Rainville. As the theory goes, when a problem occurs and triggers pain, it's your nervous system that actually adapts to the pain, and that's what makes discomfort go away, says Dr. Rainville. Exercise and movement may help your nervous system to make this adjustment more rapidly.
Understanding back pain
Degeneration in your spine is a natural part of aging. "A bulging disc, in some ways, is no different than the wrinkle next to your eye," says Dr. Rainville.
Contrary to what many people believe, only rarely does back pain strike while someone is lifting something heavy or performing an intensive activity. "In cases of new-onset disc herniation or sciatica, only 5% of people were doing anything considered heavy physical exertion, like lifting an air conditioner," says Dr. Rainville. Those things are rare. Most people are doing simple tasks, such as leaning over to spit in the sink when brushing their teeth. "I commonly hear things like, 'I was just reaching for a pencil,' or 'I sneezed,'" he says.
Back pain most often results from inevitable tissue failure caused by age-related deterioration. "There is no evidence that being careful will slow the process of disc degeneration down," says Dr. Rainville. After all, being careful won't stop any other signs of aging, such as wrinkles or gray hair.
The genetics of back pain
Your experiences with back pain may have a lot to do with your individual genetic makeup. "The symptoms associated with back pain are highly variable," says Dr. Rainville. "Pain can last anywhere from a day to three months."
And just as some people are prone to heightened pain — which may occur in people with conditions such as fibromyalgia — some people are at the opposite end of the spectrum and less prone to pain.
Research has shown that the tendency to experience more or less back pain runs in families. For example, identical twins often have similar histories of back pain, says Dr. Rainville. This is the case even if they have completely different lives and experiences — for example, if one twin has a desk job and the other performs heavy labor in construction. "These things are likely highly genetic," says Dr. Rainville.
Strategies to help back pain
The National Institute of Neurological Disorders and Stroke recommends several strategies to help ease back pain when it flares up:
Changing attitudes about back pain
While back pain may be inevitable for many people, changing attitudes about the problem could be making it worse. In the past, people used to take back pain in stride and didn't generally seek medical help. "It's only really been over the past 30 years that more and more people have been seeking health care for back pain," says Dr. Rainville. But that hasn't reduced the prevalence of pain or disability. In fact, disability from back pain has actually increased over time.
In 1990, a study ranked back pain as the sixth most burdensome condition in the United States. In 2010, it jumped to third place, behind only heart disease and chronic obstructive pulmonary disease, according to the National Institute of Neurological Disorders and Stroke (NINDS).
Where back pain was once viewed a nuisance to work through, today, back pain stops many people in their tracks. "People have gotten stuck because they've been given the advice to be careful and stop moving," says Dr. Rainville. "This runs counter to everything that was taught for decades."
Many doctors are encouraging a return to the past when it comes to managing back pain, with less emphasis on intervention and more on encouraging movement.
Treating back pain
Movement seems to be the stimulus to normalize pain responses in the nervous system. Studies on animals with spinal injuries show faster pain resolution among those forced to exercise than among those allowed to move less, says Dr. Rainville.
"This is probably the result of a survival mechanism," he says. "If an animal in the wild doesn't get moving, it is eaten or starves to death." Movement also seems to help people. "People who get moving — back to the gym, back to cleaning the house — do the best," says Dr. Rainville.
Surgery may be necessary for some back problems, such as conditions that are causing progressive nerve damage or that involve structural changes that need to be corrected, according to the NINDS. "But in a lot of cases it's less justified," says Dr. Rainville.
So, if you're experiencing back pain caused by normal wear and tear, the message is that in most cases you don't need to stop your life and wait to heal. Move your body instead.
Physical therapists can play a role in helping you gradually and safely increase your activity level, to desensitize your nervous system's response, so you can get back to your regular daily activities.