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.

MORE: https://bjsm.bmj.com/content/52/24/1543

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 [1].

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) [2]. 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 [3]. 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) [4].

Furthermore, one-third of adolescents who develop patellofemoral pain are sedentary [5]. In addition to the potential for mechanotherapy (ie. promotion of tissue repair/remodelling with exercise-therapy) [6], tissue loading through exercise can also have acute sensory effects – improving pain by reducing a sensitised nervous system through a reduction in cortical inhibition [7]. 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 [8]. 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 [9]. 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) [10].

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:

• Don't take the pain lying down. While it may be tempting to stay in bed, doing so can make the pain worse over time and actually reduce flexibility and muscle tone, not to mention increase the risk of depression. It might also raise the risk that you will develop blood clots in your legs.
• Treat the pain. Using hot or cold packs and over-the-counter pain medications won't cure the problem, but they can help make the pain more tolerable. Check with your doctor to make sure any medications you choose are appropriate and safe for you.
• Strengthen your body. While it might not be advisable to hit the gym when you are suffering with severe back pain, your doctor may be able to give you a list of exercises that can help you maintain and build muscle strength and help ease the pain.
• Seek out a physical therapist. These professionals can help you safely work past pain and teach you exercises to improve your mobility and flexibility.

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.