Disc compression on left S1 nerve root

[chak]

Hi everyone, my name is Sean

I am currently in week 20 of royal marines commando training and am 20 years old.

Sadly i have suffered a lower back injury which means i am going to be medically discharged. I was hoping to get some advice or help on a choice i have to make to do with my treatment;since it will greatly affect my chances of joining the armed forces again in the future and the possibility of physical training in the future.

The pain started in early october 2007 and persists to date. Originally, when I got the pain it ran down my left leg (can usually feel it towards the back). As well as this, i tended to get the pain when moving from lying to sitting and sitting to standing, however, the pain would dissipate after walking around for a minute or two. The only flexing problems i have are when i flex fowards to touch my toes when standing - or others which are of the same nature as that ie. sitting upright with legs out in front.

A physio on camp gave me stretches to do and cv training ie. staionary bike. However, nothing alleviated the pain, just agrivated it a bit sometimes.

After seeing an oesteopath my pain was greatly reduced so i no longer feel the pain getting out of bed, or when standing up (or when i do, it doesn't make my leg wants to give way)

My MRI results said the following:

L4/5 and L5/S1 discs have dehydrated disc bulges which are described below. The remainder of the discs appear normal. The vertebral bodies appear normarl with no focal lesions. The alignment is preserved.

Conus and causa equina appear normal

L2/3 no disc bulge, nerve root or thecal sac compression

L3/4 Mild broad based disc bulge. No nerve root or thecal sac compression.

L4/5 There is a posterior annular tear and a large focal disc bulge tending to the left which is mildly compressing the thecal sac and is also compressing the right L5 nerve root in the lateral recess

L5/S1 Focal disc bulge tending to the left compressing the left S1 nerve root in the lateral recess.

In order to stop the pain and give me a future where i can be physically active (ie.e runnning/sports etc.) i am being referred to a consultant about surgery. I am willing to go for the surgery so i can get back on track to join the navy/do sports. I was wondering what anyones thoughts might be to my results and surgery - whether my injury could get worse after op etc.

Thankyou very much for reading (if you got this far ) if you know of anything or anyone i can get in contact with inorder to get more information on the subject i'd be delighted to hear from you.

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[oscar]

Hi,

I'm a newly qualified physio so can't really offer you any advice except to think carefully before deciding whether to go for surgery or not, in some instances back surgery can indeed make the problem worse....generally speaking spinal surgery is thought of as a last resort option and given your young age, and wishes to be in the armed forces, I would really hesitate to go for surgery. I'm really sorry I can't be more helpful....there are plenty of experienced physio's on the site who will no doubt offer you some more helpful advice

The other thing you could try is if you contact the Association of Chartered Physiotherapists in Orthopaedic Medicine: ACPOM, The Association for Chartered Physiotherapists with an interest in Orthopaedic Medicine and Injection Therapy

they have a list of specialist physio's that work in that area...might be worth finding one near you that can have a look at your back and give you some advice

[Canuck Physio]

HEllo,

This is a situation where I think everyone would be a little weary to reply. Please look at all your options before making a decision, and make sure to get more than 1 opinion from a specialist. Meanwhile please read below a story that may perhaps help inform you about your journey ahead.

-------------------------
Weight training was my first great love. My dad bought me a barbell set when I was 13. With my father's encouragement, I would train in our garage every night and he wouldn’t even let my mom put dinner on the table until I was finished working out. As time progressed I moved into high school and college weight lifting in preparation for professional football ( it's called Rugby League here in Australia). From here weight training became a full time career, and for the next ten years I worked as a professional fitness and strength conditioner. During that time I appeared to be the picture of health - big, strong, lean, and very fit. However, in the process I was also slowly, but surely destroying my back.

By the ripe old age of 30 I had literally become a cripple. I was paralyzed with constant lower back pain that had turned into crippling incapacity were I could barely walk or stand long enough to make a sandwich. By this time I had not been able to sit in a chair for nearly two years. The end result was 7-hour operation and complete removal of the lower two disks in my back (L4-5,L5-S1). They were completely ruptured and had been for some time. I also required a two level spinal fusion of the lower two vertebrae involving four titanium "cages" wedged into the disk spaces. This produced permanent, life-altering mechanics to my spine. So, how the hell could this happen? Especially to me!

I was meticulous with form. After all, it was my job to analyze exercise movements of my clients and correct them. The last 3-4 years I had also been very, back-careful; no heavy squats, deadlifts or rows and I had stopped spotting the strong athletes I was working with. Stretching became a daily part of life. But the damage was already done. One thing I failed to realize, and I think many people do this, is that back injuries are accumulative.

Many times during my testosterone flooded late teens and early twenties I repeatedly strained and hurt my back doing heavy rows, deadlifts, and squats. But I was a "tough guy". I thought it would heal like any other injury and I’d be right again soon. I ignored the dull ache in the disks in my lower back and all the muscular spasms because it was "leg day" or "back day" and you gotta stick to your training schedule. Right?

Well, during this time I was placing enormous accumulative stresses to ligaments, disk material and fascia in my lower vertebrae. But unlike skin, bone, or muscle tissue these components do not regenerate when injured. They have very poor blood supply and once they are damaged, that’s it. There is no self repair. You cannot regenerate a degenerated disk, and torn fascia does not heal.

This kind of damage leaves a structurally weakened area no matter how much ab strength you have or stabilizing work you perform. In fact, I had been able to survive for so long doing what I was doing because of my excellent abdominal and torso strength. Even with two ruptured disks in my lower back I could complete the most advanced ab-stabilizing exercises. So in essence, I was perpetuating my back injury unknowingly.

At this time I was desperately trying to complete some post graduate studies and I had to complete three exams and an entire thesis lying on a Swiss ball to ease the pain! I could not sit in a chair at all. I could not walk more than a couple of hundred meters. I was unemployable for anything, and life was a misery. I was in enormous pain. Even more frustrating, there was no one that would or could help. To make matters worse, during diagnosis, after I would take my shirt off most surgeons and the spinal experts would dismiss me because I "looked too good" to have such a bad problem.

There are lessons to be learned here. You should be very aware of what you are doing in the gym. The damage may not manifest itself until many years from now! If you lift hard and heavy often, it will have an impact later in life. How early and how severe is up to you and how you smart you train. Performing heavy squats, rows and deadlifts do have their place in the strength and muscle building program. There's no doubt about it. I always was and still am a big advocate of these movements. However, I do think far more care and planning needs to be undertaken when structuring a weight training program. It may also involve far more expertise than your local gym trainer or strength coach possesses.

I look back at the "elite" programs we used to follow only 7-8 years ago, written by some of the more respected strength conditioners, and I am appalled that no one addressed this potential problem. You need to be skeptical and never take weight training programs blindly. Programs that incorporate weekly squats, deadlifts, rows, power-cleans, and shoulder presses for prolonged periods could very well be too much stress on vital areas.

Squatting and deadlifting heavy once every two weeks might also be too much. It's important to listen to your body at all times and don't be afraid to alter your program accordingly. Structure your squatting programs with equal periods of assistant/stabilizer exercises such as Swiss ball one-leg squats and lunges, barbell step-downs and one-leg presses. Maintain balanced quadriceps-lower back muscle strength and use various forms of deadlifts and extension exercises.

Also, don’t get locked into thinking that these exercises have to be taken to the max every week. You should have extended periods in your program that involve little compression on your lumbar vertebrae. Exercises like heavy, arched bench presses, leg presses, shoulder presses, and even one-arm dumbbell rows all create enormous pressure on the lumbar spine. Even something so unassuming as spotting your training partner can cause enormous strain on this area. It's important to realize that even if an exercise does not directly involve your lower back, you still need to be aware that virtually everything you do depends on this area for support.

Training with intensity, but with long term preservation in mind is a skill to be learned and perfected over years of training. Because of the training I loved to do I always thought I would have a little back pain later in my life, but I had no idea how much damage I had actually created until it was too late. Don't let this happen to you.
Article by Research Head at AU

[Yarok]

hi chack

how did your injury happen?

remember
asking neuro surgerons they advice you to get an op cos they are trained to do it.

asking hands on therapists - advise - keep it as long as u can.

leading healthy physically and mentally life you should manage without operation obviously under good therapist guidence,some aches rather will appear,

operation? as well can be solution, seen patiens in pain after 10 years post ops, or with higher or lower levels affected.

all the best

[chak]

Thank you all very much for the replies, greatly appreciated! I can appreciate why some, or indeed all, would be weary to reply since the situation is probably much more complex than what i was able to cut down into that post.

Yarok
the injury was caused by carrying a heavy bergan for prolonged periods (yomping) and intensive physical training (sometimes with webbing and rifle weighing 30lbs).

Bear with me here while i try to explain the location as best as you can relate lol...

the pain down my left leg runs from about the same height as the top of my ass crack (apologies for crudeness lol) straight down the back of my calf and dissipates before it reaches knee height.

I am fairly certain that any possible career in the armed forces is over (due to the nature of injury). However, i lead a very fitness orientated life prior to joining up - nothing too strenusous, just running,cycling,snowboarding,bodyboarding,squash etc. and want to make sure this doesn't become a chronic problem that will get worse and worse.

Again i thankyou for your posts as it does help to make things a little clearer. (as did the story of the weighlifter Canuck

[raggar]

Hey I have the same problem as you do...
L5/S1 focal disc bulge tendig to the left compressing the S1 left nerve root in the lateral recess... I had an injury in april 07 where I overshoot a jump and landed flat during snowboarding. I didn't feel any pain until the day after where I couldn't move at all. At that point I just thought that my thigh and ass area/muscles was sore and didn't bother going to the doctor. The pain felt and still feels like having a knife stabbed into the seating area and at the beginning of the backside of my thigh and going down until it stops before hitting the back of my knee. I couldn't walk straight or normal for a month or two, but during the summer I sort of got better. I could start running and slowly start playing football(soccer) and start a bit of surfing. The pain was still there but it was possible to start training again... But then during fall to winter it got worse... The pain was stronger and I stopped playing and running at the gym... At this point I went to the doctor, then got sent to a kiropraktor who thought I had an broken muscle in my thigh or something, did some streching and stuff, didn't help that much... Later on I decided to take an MR. The MR showed that I had a prolaps or a disc compreshion in my lower back that irritated the left S1 root or created pressure on it... The injury is known as isjias, not sure of what it's called in english. But anyway later on I went to a fysioterapeut and an expert on back injuries, they both concluded with that the prolaps wouldn't dry in because of my young age and that the only option was surgery... I'm basically in the same position as you are and I don't know what to do! The pain is moderate and ok to live with if you want a miserable life with pains limiting it. Or you can have an op and get well ,hopefully, or it can fu*** up your life... I don't know what to do, there must be another way out right? There has to be some other things that would heal that shit?

[physio.smith]

Sorry that you are having such a predicament about treatment. Obviously without more details etc..it is hard to advise. However has anyone within the Armed forces spoken about a course of rehabilitation / eduction. Within the MOD there are Regional facilities (such as those at Headley Court) that are set up to educate, help you manage / rehabilitate from various musculoskeletal injuries. There are generally specific back groups within a region, with physiotherapists on hand on a daily basis, they are not all able to accomodate all types of problems, but I would suggest, if you have not already, that you speak to your medical officer about your suitability to attend one of these courses. Even if you decide on surgery, it would probably be useful preoperatively...if you are not too acute or too easily aggrevated.

Good luck.

[chak]

Thanks again for the replies - i shall ask my pmo (principle medical officer) about those facilities.

As an update, i have recently just seen an orthopaedic consultant and he went over my injury and treatment etc. The outcome was that he thinks its best i leave it for the moment as he thinks there is a chance it will settle down by itself. He also ruled out surgery for the moment because he thinks that my mobility/pain isnt too much of a problem at the moment (which is true).

[raggar]

Hey fysio.smith, got any advice on my case? Read below, thanks

[physio.smith]

I am not sure what 'isjias' is in English either! Obviously without assessing you / knowing the full diagnosis it is difficult to suggest what your best course of action is.

I have treated a lot of young fit males that have developed prolapses for various reasons and it is difficult know which way any of them will go. If caught and treated quickly enough some recover well and continue strenuous exercises all be it with the knowledge they must be aware of their back, others have resulted in surgery however.

If you imagine the middle of the disc a bit like tooth paste that has squeezed its way out through a crack to press on a nerve, or like a cake with jam in the middle, if you squash one side the jam moves to the other. Anything that you are doing day / day that increases the pressure on that disc, squeezing the paste / jam more will increase the pressure on the nerve and thus the pain.

Obviously having seen various specialist they have probably given you advice on how to manage your back....a good book that you may find useful is 'Treat your own back' by Robin McKenzie. Seeing a McKenzie trained physiotherapist may be useful.

You need to look at all the activities you do day to day, the cumulative effect that these may have on your disc. Often people tend to naturally adopt a postion that eases their symptoms at the time that are actually aggrevating their problem.

I would always suggest surgery as a last option, especially if there are things that you can do / positions that you can use that improve the symptoms and that the compression is not causing weakness or other symptoms that may indicate things are deteriorating.

Good luck

[elinwee]

Hi
I am a physio with a 7 month old waiting to be fed so sorry I havent got the time to trudge through the extensive responses already posted - apologies for any repetitions!

However, I just wanted to quickly post a response based on my experience with treating back patients.

Of course its hard to make a diagnosis with an assessment in person to determine the extent of signs and symptoms. But I do agree that surgery should be a last resort decision due to - (1) it being complex surgery with variable outcomes; (2) your young age; (3) you dont seem to have given different conservative treatments a try yet to see if any of them will work.

With disc injuries, due to the mechanism of injury, my experience has been that they respond best to an extension-based program to try and resorb the protruded disc material. Therefore it would explain why cycling aggravated your symptoms, because during cycling, you prob put a flexion load on your spine which would tend to push the disc material out further. Same with sitting for a long time with legs out or with trying to touch your toes. These actions flex the spine and I would avoid them for now.

The above is based on McKenzie-theories, so yes a Mckenzie-based practitioner could help.

The initial progress could be slow - the main aim is to reduce the bulge and reduce the symptoms first. Once the injury is stabilized, then I will build on strength and movement and flexibity.

I gotta to go feed!!! Hope that helps.

Elin

[sepet]

The suggestion by the last contributor is indeed the same thing I will ask you to follow. McKenzie technique is very useful for resolving this type of back presentation. Giving that you usually feels better after walking and worse with bending down, it is even already becoming evident that you may be an extension responder. Visit this webpage The McKenzie Institute - Welcome to the McKenzie Institute International and go to the link for your country to access the specific website for that country to check for practitioners in your area.

I wish you all the best. In the interim avoid heavy lifting, avoid lifting with your back (use your leg muscles!), sit with good posture, avoid sitting for prolonged period till you see a practiotioner, avoid long car ride (which is also sitting!), stop all bending related stretches for now (it may make u worse), avoid recliners and soft sofas etc.

Sepet

[Latrobe2000]

Hi,

You really need to try a good manip physio/osteopath and Mckenzie treatment and maybe traction for atleast a few months. Obviously if your symptoms dont improve at all after that then look into surgery. I have seen alot of patients go fairly quickly under the knife having regretted it later. Dont want to scare you and would advise you going to a reputable sports clinic (eg.PURESPORTSMED) guys in london if you could get there...Not trying to give them a plug but they seem very professional- they arent cheap though...
You are very young and seem quite fit so obviously you want the BEST result and best function in the long term not just in the next few years...
would be interested how you actually injured your back- mechanism, what exactly were you doing?... Its also important when you get scans done, the physio/practitioner treats YOU and your symptoms not the scan. AS they say "treat the man not the scan". If you are going to go down the surgery path a good idea is to get a few different opinions from both orthopaedic surgeons and neuro surgeons...Not sure if the army/employer is pushing for you to have the surgery asap obviously costs them less the sooner you have it (not sure how they work so correct me if Im wrong?)... I would certainly go privately if I were in the UK myself buts thats my opinion..
Having had some experience with my training buddies getting sciatica/disc herniations it can take a long time (year) to get back to running/triathlons etc/heavy type stuff... so I wouldnt expect to be 100% within a few months....
Certainly if you are getting leg weakness also then the disc has obviously irritated/affected the nerve root and surrounding areas enough.
Definately try going back to your good osteopath or a manip physio and if youre not doing Transversus abdominus exercises yet-then you need to start now to help you stabilize and control your spine-
Sorry to sound abit stern but you want to get the best possible result for your back in the long run...Good luck and yes you need to do your physio exercises..
cheers janak

[jrcacupressure]

So sorry to hear of your plight. I am sorry for you, but also sorry for the pathetic system that exists in the armed forces these days. There were always top notch orthopaedic and sports medicine physios at Lympstone (Royal Marines) and other Forces training establishments to give advice on and treat such conditions conservatively. Due to Government cut backs etc etc these are now no longer available - even army personnel returning from Iraq and Afghanistan have to 'queue up' for NHS treatment - it is an unbelievable state of affairs. If you want to send me a private email I may be able to recommend someone who may be able to help you - all depends where you live. Best wishes - John

[Judith Mollet]

There's been lots of sensible advice for you Sean; get a good physio, Mackenzie works for alot of patients; and the "watch the training" story from Canuck physio gives a message. It's tough that your back doesn't seem to have taken to life in the marines but I'm sure you will manage in the long run even if you have a complete change of career direction. When I was a sporty young newly qualified physio 20 plus in the UK then in Switzerland I did: walking -climbing -trekking -aerobics -tennis-jazzdance- ski touring -mountaineering -jogging -swimming etc etc and of course physio full time. All the resisted manual exercises I did for my patients combined with my energetic free time carrying heavy backbacks gave me two central disc protusions and weird pains down both lages that bothered me for years and made me rethink and redirect my sports. And believe me there is a life out there after the initial confrontation with the awful truth that not all backs like everything we do with them! Now aged 53 I do long cycle tours over walking paths for fun (uphill downhill) and ride horses for hours every week. Being a physio I of course believed I needed physio training exercises and mackenzie and fitness gym stuff to be fit to ride. So I irritated my back 10 years ago again by doing it all under expert supervision. Shit happens. No more gym workouts. Today I have the best core stability I've ever had by riding and grooming horses. I also help the blacksmith now and then lifting the hooves for up to 2 hours without dying horrrible deaths afterwards. Also work as a physio half time. Never felt better! Wish you all the best and good luck with all the decisions that are coming up.

[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

[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.

[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.