Disc compression on left S1 nerve root

[physio.smith]

The system for the MOD is far from perfect as far as physio goes, but in my experience it is not all bad.

There are Regional Rehabilitation Units in various parts of the country now, dealing with the rehabilitation of a variety of conditions, in a group environment, but individually tailored, with 1 on 1 treatment where required. These generally have a clinical specialist and assessments are mainly headed up by sports medicine trained doctor or specialist in the area the patient has been referred to.

There are also primary care facilities available at a lot of MOD establishments. In my area the RRU and primary facilities are well established. Generally acute patients are seen within 5/7 and chronic within 10/7. Obviously this does change with fluctuating referral levels pre and post deployment and during block leave periods. My experience has been that extra money was made available for an additional physio, for conflict related treatment and a specialist physio was funded for to allow a patient to continue to stay in his local area for treatment.

While this may not be the case everywhere and yes there is still a lot of room for improvement it is not all bad when it comes to physio.

One of the biggest mistakes that has been made is the closure of specialist MOD hospitals and there are still too many things that the soldiers have to wait on NHS lists for.

In my opinion they deserve the best treatment that is available for them. With more specialist facilities and private speed referrals for all problems.

Headley Court is always a good source of information to find your nearest rehabilitation unit, otherwise keep pestering your medical officer. There may be information available online if you know where your nearest establishment is.

Good luck

[monkey]

Too much talk about damage and having to have things done here. What about evidence based answers.
No one seems to have mentioned that disc prolapses resolve, without any intervention, over time. Jensen, Albert et al did a very interesting study a couple of years ago where they MRI scanned patients to confirm disc bulges and re-scanned them 14 months later and the majority had fully resolved without any intervention. Interestingly the larger the disc bulge the greater the probability of natural resolution. This includes discs causing nerve root compression.
Next fact: surely qualified therapists recognise that there are plenty of people walking around with disc bulges or severe degenerative change that are not suffering any symptoms and can lead a perfectly active life. Pain is everything, if the patient is not suffering pain (or major neurological compromise) then a disc bulge or degenerative change is of no concern.
If symptoms are resolving then leave well alone, natural recovery is best. Do not have things done to stop you having problems in the future. Treatments are there to get you through a bad episode, not to stop you having problems in the future, and sometimes surgery is the best answer. If anybody has true evidence, not just opinion, regarding interventions that stop flair ups of pain then please let me know.
Standard advice: it is normal to have flair ups of pain, this does not mean you have re-injured your back.
The best advice I can give is to gradually increase physical activity, with common sense. The more physically fit and healthy you are the less likely your back is to cause you problems in the future.
Unfortunately there is a genetic link and some people just are not made for very physical work. So if there is a family history of back problems, from a young age, it may be best to accept that you have to find a less physically demanding career. But remaining physically fit is still important. I hope you continue to recover and are able to return to normal activities as soon as possible without fear of "injury".

[Canuck Physio]

Too much talk about damage and having to have things done here. What about evidence based answers.
Unfortunately back pain in general is one with limited evidence base when it comes to treatment or solutions!
No one seems to have mentioned that disc prolapses resolve, without any intervention, over time. Jensen, Albert et al did a very interesting study a couple of years ago where they MRI scanned patients to confirm disc bulges and re-scanned them 14 months later and the majority had fully resolved without any intervention.
This is true, however the issue is managing the current problem (pain is reported) and allowing the individual to return to top performance. As well chak states that he has reduction in pain from osteopathic treatment (no mention of what).
Interestingly the larger the disc bulge the greater the probability of natural resolution. This includes discs causing nerve root compression.

Next fact: surely qualified therapists recognise that there are plenty of people walking around with disc bulges or severe degenerative change that are not suffering any symptoms and can lead a perfectly active life. Pain is everything, if the patient is not suffering pain (or major neurological compromise) then a disc bulge or degenerative change is of no concern.
This individual is experiencing pain, as well the previous occupation (marines) and age of the individual are important (20). In relation to the article I posted (I know it's long), it is very possible that poor technique, compounded with strenuous and fatigue inducing field training could have resulted in poor biomechanics during certain movements, repeated over time to give a general rise to such problems (similar to that in the article).
If symptoms are resolving then leave well alone, natural recovery is best. Do not have things done to stop you having problems in the future. Treatments are there to get you through a bad episode, not to stop you having problems in the future, and sometimes surgery is the best answer. If anybody has true evidence, not just opinion, regarding interventions that stop flair ups of pain then please let me know.
Pt reports at least 1 form of Rx has alleviated pain (pts main concern), additionally pt wishes to improve function in the future --> thus some form of management plan may be useful
Standard advice: it is normal to have flair ups of pain, this does not mean you have re-injured your back.
How can we manage these flair ups. As well is it useful to take the "wait and see" passive approach to therapy?

The best advice I can give is to gradually increase physical activity, with common sense. The more physically fit and healthy you are the less likely your back is to cause you problems in the future.
Much of the evidence regarding back pain indicates that general exercise is useful.

Here are some interesting facts:
• Of those with acute back pain 60–70% will recover within 6 weeks
• 80–90% within 12 weeks
• 2-7% of people with acute back pain develop chronic back pain
• Flexion/extension exercises massage, heat, traction and ultrasound have all been used as interventions however the effectiveness of each is still being investigated

Unfortunately there is a genetic link and some people just are not made for very physical work. So if there is a family history of back problems, from a young age, it may be best to accept that you have to find a less physically demanding career.
I do not believe this, to reiterate "where's the evidence"? Too often genetics is used to write off much of what can not be explained, or when researchers lack the common sense to make a firm conclusion about their findings. I completed my first degree in Cell Biology and Genetics btw, so I will happily read whatever evidence regarding genetics is available
But remaining physically fit is still important. I hope you continue to recover and are able to return to normal activities as soon as possible without fear of "injury".
To quote Physio.ca "Physiotherapy - It will move you"

Some useful refs:
The back pain revolution. Second edition, Gordon Waddell 2004.

PB Polatin, RK Kinney, RJ Gatchel, E Lillo and TG Mayer, Psychiatric illness and chronic back pain. The mind and the spine—which goes first?, Spine 18 (1993), pp. 66–71

Andersson, G.B. (1999) Epidemiological features of chronic low-back pain. Lancet. 14 (354), pp.581-585.

PG Shekelle, M Markovich and R Louie, An epidemiologic study of episodes of back care., Spine 20 (1995), pp. 1668–1673

Koes BW, Bouter LM, Beckerman H, van der Hiejden GJMG, Knipschild PG. Physiotherapy exercises and back pain: a blinded review. 1991; BMJ 302: 1572-6.

[elinwee]

I am sorry but MONKEY seem to have taken a hard stand where evidenced based practice is concerned.

Are you implying that if there is no evidence then dont treat? If that was the case, then, then why are physios still using electrotherapy, why are compensible bodies paying for 20mins of treatment time, why do people still have back surgeries?

Just to clarify, I am FOR research and collecting evidence, but I believe that its not black or white where applying evidence is concerned. I worked in research for a while and one of the things I learnt is that in conducting an RCT (the best level of evidence I believe), one can NEVER achieve a homogenous population during the investigation. Therefore, the results are as generalisable as the population is. If that was the case, how can one take a hard line on evidence based on a statistical majority of a specific population?

Research will never be perfect, and hence neither will the evidence. Patients will never be the same either, even if they had the same sort of injury. It is thus up to the therapist to utilize their knowledge and skills, incorporate what they know of the evidence and apply the above into a management plan best fitted to the individual client, bearing in mind that if they didnt get it right the first time, that they have a strong base to reassess and reformulate their treatment.

General exercise is a good principle for treating most musculoskeletal injuries. But when one is faced with symptoms resulting from an injury, it may be hard to know what is "common sense" when it comes to exercising and that when I believe a trained physio is invaluable to set one on the right track.

The best evidence that any therapist can apply to their clients is NOT to utilize treatment techniques that have poor evidence-base AND poor physiological-rationale with poor treatment outcomes.

[monkey]

Sorry I have caused some confusion. My whole point is that nothing is black and white and that pain control is everything. Pain does not equal damage. If seeing an osteopath helps ease the pain it has solved the problem. If applying ultra sound eases the pain it has solved the problem, but please do not start talking about things in term of damage. Rarely is damage a reason for a persons on going pain and functional restriction. Yes, I have read Waddell's Back Pain Revolution, and I am sure this is his major point.

Where do your figures for the natural history of back pain come from? Here are the ones that I use:

Persistence for several months is common:
Linton et al (1998) 43%
Hillman et al (1996) 47%
Waxman et al (2000) 42%
Szpalski et al (1995) 36%
Croft et al (1998) 75%

Symptoms Are Slow to Resolve After 3 Months
LBP after 3/12 44%, LBP 12/12 40%. (Philips & Grant 1991)
LBP 7/52 54%, LBP 12/12 42%. (Cherkin et al 1996)
LBP 3/12 48%, LBP 12/12 42%. (Thomas et al 1999)

Relapse is common
Proportion of patients with more than one episode in a year:
Linton et al (1998) 57%
Brown et al (1998) 55%
Heliovaara et al (1989) 45%
Toroptsova et al (1995) 65%
Klenerman et al (1995) 72%

Regarding the genetic link look at "Genetic Factors associate with lumbar modic changes" Daavittila et al. The conclusion states, "Genetic variations in IL-1 cluster and MMP-3 gene were found together to associate significantly with type 2 modic changes".
Ken Cheung (Hong Kong) has been doing some recent research on the Genetic link. I have been unable to find the specific paper I got the quote from but it does seem that people that are genetically pre-disposed to Back Pain are 10 times more likely to suffer with back problems in a manual job than those that do not have the particular gene. There is no increased incidence in non-physical jobs.

I am not suggesting that only approaches with very good evidence are considered. The interventions used obviously depend on the individual patients presentation and the clinician’s assessment. I did not mean to imply that because natural recovery occurs you should not do anything. Most patients do require some kind of help on the road to recovery. I am a manual therapist of 20 years experience, specialising in LBP, not an academic, and I use all the interventions that most therapists use but I think it is important to let patients know what evidence is out there. So my first reply to “chak”, who started this thread would be to give him the hopefully re-assuring bit of evidence that most disc prolapses resolve with time, he just needs help to get him through this particularly painful part of his life.

Have you read Explain Pain by Lorimer Moseley?

[Canuck Physio]

Hello again,

Thanks for the references, that is useful. The evidence based guidelines in the UK, and the opinion of the leading pain researcher (Uni of leiscster Dr Paul Watson) suggest that non specific back pain is a common cause of work related absence, and that chronic pain issues need to be evaluated as either a true physical problem, or whether psychosocial issues are of concern.

I never like to share comments without backing up with evidence, but this time I have to draw on something from personal experience:

Having previously suffered back injuries myself, I do not agree that pain control is everything. If that were the case for me, I would have simply had doctors inject and drug me up with everything they got and become a sedentary lifeless bag of mostly water and protein.

As well I was not specifically referring to Dr Wadells book, I was refering to the previous post dated: 18-01-2008 04:04 PM, in which I described a story related to me by a researcher from Aus. In his case, low grade repetitive stress injuries resulted in a significant chronic problem. There are indeed microscopic, and even macroscopic changes that do occur that can significantly effect the biomechanics, tissue viability, strength, bone density, hydrostatics, of the complex low back area. I feel for 'chak' that it will be important to monitor and manage the problem, while find ways to continue to increase activity without aggravating the low back. Whether this correlates with what is observed on radiograph or not, is obviously difficult to say for sure.

Hmm... I am not going to completely criticize the research around genetics, but I will look into it and report back what I find. Regarding genetics in general, we know that everything from what we eat, how we exercise, what we think, sleep, and feel influences our genes. Whether this research shows that certain allelic version of a gene contribute to back pain or not can not be used to confirm a hypothesis. The results of their study may not distinguish between gene activation, and gene presence.
For example recent research surrounding the French Paradox: . Looking at the the obvious (Americans eat 70g of fat/day in diet, get 50% more cancer vs. French eat 100g of fat/day have less cancer, diabetes etc.). If scientist A discovered that in French gene X was more common, it is absolutely a ridiculous statement to simply report the difference in mortality on genetics alone. The reason being that scientists have deduced how certain food compounds can directly activate what is now termed as 'longevity' gene SIRT-1. It is the influence of the frequent consumption of the food compound that activated gene SIRT-1 over time, not an inherent genetic difference that can explain the difference between the 2 groups.

Myth Number 1: Genes Are Everything

The so-called twin studies have proven that beyond a doubt. In those research studies it was revealed that when identical twins - those with the exact DNA - were separated, they did not develop the same health issues.

It's what your genes are exposed to that determines the level of health that one has. It's the signals that you send to your body by the food you eat, the thoughts you think, and the life-style choices that you make that affect the health of your genes.

Your actions, not only your genes, influence your life to a very large extent.

People who lead mentally stimulating lives, through education, occupation, and even leisure activities, have a reduced risk of a variety of diseases. Some unscrupulous researchers fail to take lifestyle into account when attempting to explain the cause of diseases such as Alzheimer's, Arthritis, Obesity and others.

The same explanations have been given to explain obesity (which surely must be genetic right?) and that is why some researchers are hard-driven to find the 'obesity' gene, failing in attempts to understand the role of leptin, ghrelin and other molecules, as well as the genes that are activated more often in obese individuals. Is there a link between obesity and OA, how about family history?.

This is a condensed attempt by me to try to explain the reason why I am weary about any 'genetic' findings in relation to incidence of anything in particular.

I will discuss this further without hesitation of course.

I absolutely agree that this patient needs help, and indeed I agree the advice you have given is very much important.

I hope whatever I have said will be looked upon with an open mind, and mind my criticism it is not meant to be aggressive in any way

Regards

[MickyB]

I would like to add my 2p's worth!! . I live in a garrison town and as soon as I saw the post was from someone in military, I knew, if it was a consult, the first thing I would investigate would be the yomping + weight in backpack. It is this factor more than any other, in my experience, that hurts backs. The more important issue is the recovery therefrom.

However, I would totally agree with Canuk Physio regarding the genetic level. It is virtually impossible to separate genes from inherited characteristics through proximity; or cellular compromise through diet; or familial emotional holding patterns etc or any other kind of combination of cultural influences with their attendant benefit or otherwise. Where our attention is focused is where our experience happens. What we believe about this focus is what we actually experience.

We consult an expert and accept their pronunciations - this also has a profound effect because we assign a far greater weight to their words than others.

First off Sean, don't worry about getting better AT ALL!

Second, use core, deep squeezing to connect you as vitally as possible with the deepest balance of your spine.

Third, if it makes you feel better keep doing it, if it makes you hurt, stop for a while and maybe come back to it.

Try something which focuses on core balance, like pilates or yoga. You are the one inhabiting the structure and no one can become more expert in what benefits and what doesn't than yourself.

[chak]

hello!

sorry its been 2 years since i replied to this thread - but better late than never =)

after my medical discharge I was still suffering the same symptoms of really bad sciatica from my lower back, down my left leg to about my knee (down the back of the leg).

I wasn't in favour of getting surgery and remedial work wasn't really helping too much either. However, I came across IDD therapy when browsing the net for lower back problems. I spent my compensation money on getting this done as it was non invasive - and i thought it was better to try to spend my compensation on something that would help in the long run, rather than waste it on trivial things.

after 3 months my treatment was complete and my sciatica had gone - i was only left with a tiny niggle that i noticed on rare occasions. At the moment im as active as i used to be and am hoping to rejoin the forces - although this time it'll be the navy, none of that bergan-yomping to be done there! =)

However, i would just like to say a big thanks to the guys who took an interest and offered help, i really did/do appreciate it (even if i disappeared for a wee while!).

If you wanted to read more about the treatment I got there is a link to the site I went through to get it:

IDD TherapyÂ. No surgery. No injections. And for the majority of patients, no more back pain!

(edit: monkey previously noted that disc compression can resolve itself after 14 months. I dont want to say that the idd therapy is the sole reason im good now, but it seem to do it for me )

[housefull]

Good luck with whatever it is that you end up doing.
Always people on here that can give you advice in the future should you need it.

[chak]

Yeah no worries

ironically, the day after posting that, I inflamed some soft tissue in one of my lower back factets (if i remember hearing the osteo correctly). Spent the whole weekend stuck in bed! - thought i'd prolapsed another disc it was that painful haha. Very relieved it wasnt!

[elinwee]

Thanks to MONKEY for clarification. I didnt mean to jump down your throat and apologise if I did or seem to come across. I do have an issue with how the term "evidence based practice" is used and how its being applied to real-life practice/ clients.

I am a much lesser experienced practitioner than you are and certainly far far less read then you!!! Thanks for the useful references - I will certainly look them up. I have always been a more "touchy-feely" therapist than one to look at strict theories and rationales, but I had a mentor who showed me how impt it was to combine good manual skills with strong theoretical basis, and practically forced me to also strenghten my theoretical base, and made me a heap better therapist. So I always appreciate being reminded re the academic side of things too.

When I started to utilise Clinical Pilates as part of my skill repertoire, I started to learn not to fear pain in the rehab process of exercising as I now had so much a bigger exercise base to work from with people who are highly sensitised to pain behaviour from prev injuries/ experiences so I fully agree that rarely ongoing damage/ injury is the real reason for a person's experienced pain and functional restriction.

Thanks for taking the trouble to clarify your stand. Anyway, this thread seems to have veered off its original track and the original poster havent seem to have had another look in! Hopefully he has got the help that he was looking for.

Cheers.

[chak]

Hi - sorry its been a little while but got caught up in all the paperwork involved in leaving the froces

Been reading through all the replies and cant thank you all enough for responding and giving me more of an insight into it all.

dont have time to write a proper reply to you all at the moment because im just on a quicky break and have to fall in again shortly but will be back on asap.

[physio.smith]

Good luck with whatever it is that you end up doing.
Always people on here that can give you advice in the future should you need it.