Chronic back pain is caused by a number of different contributors, and is defined as back pain that lasts longer than three months or that occurs episodically. It can affect people of all walks of life, regardless of age or physical condition.
The medical community doesn’t understand everything about chronic back pain yet. Questions persist on why some people have it and others don’t; or why some episodes last longer than others; and why imaging results don’t always paint the correct picture. Imaging and blood work may even show things like lumbar degeneration or disc herniation, though these findings don’t prove useful because these positive findings often don’t come with pain or other symptoms at all. On the other hand, so many people with chronic back pain will receive no positive findings from blood work or imaging at all.
The good news is that backs are just like any other body part, and the will heal.
We do have a good understanding of some common causes of chronic back pain as well as an understanding of how pain can manifest itself. Many people experience going to bed feeling fine and waking up with significant back pain. This can be caused by swelling of a disc as it re-hydrates during the night. Another common trigger is doing something simple like reaching for the milk carton and the back suddenly spasms. This is the result of poor motor control and the spasm is a protective mechanism. Sometimes it is more obvious and we experience pain during an effort of some kind like sneezing or lifting something heavy. However focusing only on the possibility of what has been “damaged” can lead us into unnecessary imaging, inappropriate treatments and much higher healthcare costs while still not solving the underlying problem.
Pain is defined as an unpleasant physical and emotional sensation that we experience when injured OR when there is a threat of injury and no actual tissue damage present.
It is a protective mechanism our brain uses to keep us from getting hurt. It has biological components, psychological components and sociological components. Unfortunately, we can get stuck in a loop where we get very good at experiencing pain and our brain tells us our back is hurting even when nothing has been done to injure it. This short video does an excellent job of explaining further.
If you experience this, here are some things to consider.
- Your back will heal- just like an arm or an ankle. If you twist your ankle one year, and then several years later you do it again, you don’t become fearful of having a ‘bad ankle’. The same holds true for your back.
- Move around as much as you can as pain allows. Moving is better than resting. If it isn’t resolving quickly, considering seeing a chiropractor or physical therapist. They are trained to help relieve your symptoms and give you the tools needed to reduce the likelihood of future episodes, and help you learn to better manage such things on your own.
If your chronic back pain is constant and not episodic, then a multi-modal approach is best, especially if it hasn’t responded well to individual treatments. There is excellent evidence for a multidisciplinary approach as well as solid evidence for exercise therapy and spinal manipulation. You can read the full guidelines from the American Academy of Family Physicians here.
You should have a team that includes a pain management physician, a chiropractor or physical therapist and a mental health therapist that work with you to help with your symptoms. A psychologist trained in Cognitive Behavioral Therapy can be very helpful in these situations. If you’re having chronic back pain and have questions, please feel free to email me at [email protected]
Samuel S. Spillman, DC
Frozen Shoulder is real, and doesn’t only occur in the winter! Generally the condition doesn’t have a definite start point, ie. patients often can’t think of an injury that started the pain. Some warning signs to look for include pain and a loss of motion in multiple directions.
Medically termed adhesive capsulitis, frozen shoulder is a condition that affects the capsule surrounding the shoulder joint. The capsule is a sheath of tissue that maintains fluid within the joint and maintains pressure, ensuring relative stability. Inflammation causes the capsule to become more fibrous and thicken. This causes limitations in range of motion and pain. If your shoulder is feeling stiff and painful, with loss of motion in multiple directions, you may be facing frozen shoulder. Identifying it early is the best
way to help effective progress.
Who gets it?
Although anyone can get this condition for a variety of different reasons, there are a few predisposing factors:
- Most prevalent in women ages 45 to 65
- Diabetes and Thyroid disease
- Previous episode on opposite shoulder
- Immobilization of the shoulder following certain surgeries
- This condition can also develop after a minor shoulder injury
There are 3 overlapping stages of the condition called the freezing; frozen; and thawing phases. Each stage has certain treatments that may be beneficial to help speed recovery, which will be discussed below.
Recovery from the condition generally takes anywhere from 6 months to 2 years, and has the following stages and interventions that can help at each stage:
The Start (months 0-3)
What to expect:
- Pain begins with no initial injury, can be sharp and/or dull in nature
- This is when inflammation occurs, but adhesions haven’t formed
- Pain most notable at endrange movements, but can be present at rest
- Trouble sleeping is common
In this stage, you should see a physical therapist for a few visits to learn exercises to maintain range and slow the loss of motion. You will also be educated on the condition and general progression through the stages.
A few tips:
- Use the shoulder as normally as possible without exacerbating symptoms.
- Intense stretching or manipulation techniques are not advisable in this stage, as they can lead to greater losses in mobility and increases in pain.
- Listen to your body, if your causing a significant increase in pain you’re doing too much
- Keep contact with your PT during this stage; activity or exercise modifications are often needed
Freezing (months 3-9)
What to expect:
- Loss of motion in all directions, with external rotation and raising the arm to the side are usually most affected
- Range of motion becomes progressively worse
- Daily activities (reaching, dressing, bathing, workouts) can become more uncomfortable
- Increased inflammation and blood flow present within tissue
Physical therapy continues to be beneficial in this stage to maintain ROM and function. PT interventions will be tuned to the amount of tissue irritability the patient is experiencing.
A few tips:
- Continue using the shoulder as normally as possible
- Performing range of motion exercises will be helpful in maintaining range
- Listen to your body, if there is an increase in pain with activities and exercising, there may also be an increase in inflammation
- Keep contact with your PT during this stage; activity or exercise modifications are often needed
Frozen (months 9-15)
What to expect:
- Increased fibrosis = increased loss of motion
- Your joint will be much more stiff, but pain will begin subsiding
- Your shoulder is likely to have large range of motion deficits in this stage
You will likely be working with a home program for care at this point. Let your PT know if you have any changes that you have questions during this stage.
A few tips:
- Once again, continue using that shoulder as normally as possible
- Try to avoid movements that are too uncomfortable to complete
Thawing (months 15-24)
What to expect:
- Pain will begin improving, and eventually resolve
- Significant stiffness will remain, but will improve slowly
- Minor range of motion loss may persist after resolution
- Fibrosis of joint capsule, but decreased inflammation
The shoulder will begin During this stage you should begin appointments with your PT for more intensive stretching and manual therapy. Functional strengthening exercises will be used to begin returning the shoulder to normal.
A few tips:
- Intense stretching or manipulation techniques are not advisable in this stage, as they can lead to greater losses in mobility and increases in pain
- Begin a strengthening program that challenges your range of motion as well
- Be sure to work with your PT to develop a comprehensive program to return your shoulder to normal
Treatment of frozen shoulder can be long and arduous, but arming yourself with information can be one of the most effective tools. Make an appointment with your physical therapist or chiropractor to learn more about the condition and how you can manage it effectively. Remember, early intervention and education is essential for recovery.
Bryan Esherick PT, DPT Have questions? Email me at [email protected]
Information adapted from the clinical practice guidelines Shoulder Pain and Mobility Deficits: Adhesive Capsulitis from the JOSPT.
Have you ever experienced knee pain when beginning a new activity or increasing training volume? Does this pain go away after the warm-up, but come back the day after or when stopping the activity? You may have been of the lucky ones if these symptoms were short lived and went away within a few days. For many, this pain can become a chronic issue and affect everyday activities like sitting, stair climbing, and walking. This chronic condition is characterized by pain in the patellar tendon.
Jumper’s knee, runner’s knee, or patellar tendinopathy are all synonyms for this common condition. It generally affects the adult population ranging from 16-40 year olds, but can affect anyone if a training schedule is not properly developed. The tendinopathy is generally due to overstressing a poorly conditioned tissue, which can eventually lead to tendon dysrepair. Just like your muscles, bones, tendons, and ligaments also have to be trained to meet the demands you are putting on them. The reasons for pain with this condition is poorly understood, but it is believed that the brain and central nervous system play a big role in sensitization of the tissue. Once this process begins it is hard to reverse, which is likely why symptoms can last anywhere from a few weeks up to 2 years.
No matter the activity, whether you are increasing your training volume, load, surface, or equipment the degenerative process may begin. The importance of ramping-up training or allowing appropriate time for tissue adaptation can not be overstated. This is why this injury is more prevalent at the beginning of a sporting season or training regimen. Have you ever wondered why marathon runners are very calculated in their training regimens in terms of increasing mileage? This condition is one of the reasons, as all tissues take time to adapt. Remember, the preseason is what prepares your body, and may be the most important part of the season to reduce injury risk.. Check out our upcoming blog in the spring on how to prevent training injuries.
As always, better outcomes are seen with more timely interventions versus the wait and see method. Treatment is generally aimed at reducing pain, reconditioning the tissue, and improving proprioception in the joint and surrounding tissues. Eccentric and heavy slow resistance exercises have been shown to be the most beneficial in treating this condition, and certain protocols have been established. Since everyone’s tendon quality and pain levels may be different, it’s essential to ensure you are starting at the right level for your state; if the tendon is stressed too much during recovery, the tendinopathy cycle will repeat itself and may become worse. Remember, there is no established timeframe for recovery, so being patient with recovery is important. The good news is that you can usually continue training, but it is best to consult your physical therapist about possible changes in impact training, training load, or training volume. Cookie cutter approaches to treatment won’t work, so be sure treatment is properly adjusted to meet your needs.
Bryan Esherick PT, DPT
It is that time of year again, the birth of a new year and maybe a new you. Are you making any New Year’s Resolutions? In the fitness and health care communities we tend to focus a lot on losing weight, diet, starting an exercise program. And all those are wonderful things. But I think it is important to focus on what will make your life better. What kind of resolutions will improve YOUR life. Not necessarily what your healthcare provider would choose for you, or your spouse, or your parents. We might want to swear less, or improve a relationship with a loved one, visit family more, get a promotion at work, get more involved with charity, and so on.
Whether you are trying to resist something that is bad for you or start a new thing that is good for you, making a change can be difficult.
I like to start with the end result and work my way backward. For each goal, I like to make it SMART: Specific, Measurable, Attainable, Realistic and Timely. This is a commonly used business idea, but it can be applied to personal goals too. To me, using this method can help really set ourselves up for success.
For me, less screen time in the year ahead is a big goal. You may have noticed that it is more difficult to NOT do something than it is to add a new activity. So instead of setting a screen time limit for myself, I’m endeavoring to fill up my time with other things, so that screen time is less of an option outside of work. I’m making a list of books I’d like to read, and a commitment to do more activities after work. I’ve joined a committee of a local charity and I’m going to attend one evening jujitsu class a week.
So as you make your New Year’s Resolutions, try to spend time planning out how you might achieve your goals, as well as determining what goals to set.
You’ve got this. Happy New Year!
Sam Spillman, DC
Insurance coverage can be a tricky thing to navigate. Do you know what your individual deductible is? If so, do you know about your family deductible and coinsurance for a specialist visit? For most of us, myself included, the insurance specifications have become seriously complex. Many times I’ve intervened on behalf of patients that have met their wits-end while attempting to understand their chiropractic or physical therapy benefit coverage. In an attempt to simplify some of the frequently used insurance terminology, I put together this little cheat sheet to help in minimizing the frustration factor.
A coinsurance occurs when there is cost-sharing between the insurance company and the covered member/family. The insurance company may tell you that your responsibility is a 20% co-insurance and that they will cover the rest of the charges (remaining 80%). Quite often a coinsurance comes in to play after an individual or family deductible has been reached.
Example: Your opthamologist visit is $400 and Optima informs you that you have a 20% coinsurance after meeting your $200 deductible. Currently, you have met $0 of your deductible. Your responsibility would be: $200 of the deductible and then 20% of the remaining $200 specialist visit charge = $40.00. The total you can expect to pay for the visit is around $240.
A copay is a set fee that you are responsible for each time you visit a doctor. There are usually tiers or copays where a primary care doctor is typically less than the copay you may have for a specialist. Some plans have a copay due in addition to a co-insurance.
The set amount an individual or family must reach before transfering over to coinsurance coverage for medical services. Some plans have relatively low individual and family deductibles of $200 – $500 while other plans have larger $5000 – $9500 deductibles. Once you have met your deductible you may only be responsible for a fraction of the percentage of your medical care, referred to as a co-insurance.
Out of pocket maximum or stop loss
This is the absolute maximum a covered member or family will pay out of pocket for medical care including copays, deductibles and co-insurance for a defined period of coverage (usually a calendar or a contract year)
Treatments come in a variety of options. Opioids (oxycodone, hydrocodone, etc.) are often prescribed as treatment for an episode of pain patients are experiencing. If you haven’t been the recipient of these directly, there’s a good chance you know someone who has. They’ve been widely prescribed as they had always been considered both safe and effective. However, in the wake of an opioid epidemic, we want to remind our patients that there are safe and effective treatments that let you avoid the drugs – and without the side effects, That said, there are instances where these types of drugs are appropriate – post surgery or serious injury – and with proper management may be used safely. However, we want to use this platform to highlight our approach to more conservative treatments that can effectively alleviate pain.
As physical therapists, chiropractors, and massage therapists, we look to provide that first-line treatment for acute and chronic injuries alike – including: manual therapy; joint mobilizations; massage and soft tissue release; targeted therapeutic exercise; and health education. Let’s take a closer look at these distinct areas.
Joint Manipulation and Mobilization
Manipulation and mobilization are used throughout musculoskeletal health by chiropractors, physical therapists, and some osteopathic doctors. Despite popular belief, the aim of these treatments is not to put a bone back in place. Treatments like this work with the nervous system to affect pain (through release of endorphins), muscle tension (through reduction in pain and thus reduction in spasm), and proprioception (your brain’s sense of your joint position). In my opinion, 95% of cases require exercise to reinforce the effects of the manipulation. In other words, mobilization and manipulation gives your body a window to exercise with less pain so that you can correct the issue at fault and increase muscle tone. However, it does not correct the underlying cause of the pain independently. These are powerful pain relieving tools that can be employed to aid in your recovery from pain, especially in the spine.
Generally massage is thought of as a relaxation and stress reducing technique, but it can also be used as a powerful pain relieving and recovery tool. Therapeutic and sports massage are given in order to improve recovery through reduction in muscle tone and improvement in blood flow. Relaxation in muscle tone allows the muscle to receive the adequate nutrition is desperately needs to heal. Think of a muscle as a sponge; when it is squeezed out (overactive) it is not able to receive the water (blood) it needs to function. We see this happen often in cases of back pain associated with sustained postures, and receiving occasional massages would help alleviate this chronic paid in a more effective and cost-effective treatment. Massage also releases endorphins through a healing touch and targeted techniques, which helps to ease pain and creates a relaxing therapeutic environment for the body to heal. Your chiropractor or physical therapist may also use targeted soft tissue techniques to promote healing and pain reduction.
Therapeutic exercise is used widely by physical therapists and chiropractors as well. Movement encourages the body to release endorphins, reduce tissue tension through increased blood flow, promote healing through cellular processes, and prevent chronic pain from fear of movement. Exercise can be used as a means for tissue to adapt and heal to specific stresses it will encounter through daily activities. We use therapeutic exercise not only as a pain relieving mechanism, but also as a way to introduce stress to healing tissues in a controlled manner. If the tissue is not properly loaded over time, it can be substantially weaker than it was prior to the injury causing recurrent injuries. The best example of this phenomenon is chronic ankle sprains. Without proper rehabilitation, ankle sprains are likely to keep occurring as the body is unable to fully heal the tissue prior to sustaining a second, third, or fourth injury. Another common misconception is with arthritis. Many people stop moving because the arthritis is causing too much pain. On the contrary, our joints need to be loaded in order to provide nourishment to the joint surfaces. Without movement, joints can continue to degrade and become more painful. Remember, movement is your friend and is ultimately what will keep you feeling happy and healthy for years to come.
Education about a particular condition should not be taken for granted. It is the responsibility of your healthcare provider to educate you on your conditions, the treatment options, and expected recovery prognosis. Please don’t hesitate to ask your provider questions – fully understanding your condition is a key element to complete recovery. Education about pain can also be invaluable for the patient, which is why our office strives to provide pain education to help contextualize thoughts and beliefs about pain. Sometimes education is the stepping stone to preventing a patient from progressing to a chronic state of pain. For this reason, our office doesn’t just treat your condition, we help you understand it.
As you can see, there are many alternative treatment options for pain relief – and with far fewer side effects – than prescription drugs. It is important when seeking care for pain, that you explore all options landing on an course of treatment. Second opinions can often be helpful when you are unsure if a certain treatment is right for you. Trying a more conservative option first may save you time and dangerous side-effects from other riskier alternatives.
Our office uses all of the above techniques, and when necessary, uses other techniques including modalities and dry needling. Our goal is to provide our patients with the most comprehensive, evidence-based treatments to ensure the fastest and most complete recovery path from injury. We ensure that each patient is treated individually, as every patient has different needs from the healthcare system. Still have questions? Give us a call to learn more. We’d love to help you become the strongest version of your best self!
Bryan Esherick PT, DPT
Here are some backpack tips to lighten the load:
- Choose a backpack that has two wide straps with good padding to distribute the load evenly.
- Adjust the height. Tighten straps so the bag is centered on the back, ideally above the lower curve of the spine.
- Use both straps. The one-shoulder method may be cool, but it adds serious pressure and throws body alignment out of whack.
- Weigh the bag. It should weigh no more than 10% of the child’s weight. If your child regularly has to carry more than that then you should get them one of those rolling backpacks that they can pull.
- Have your child checked. If your kid complains of back pain-even if it seems minor-talk to your doc. No amount of achiness is normal, and a physician can recommend strengthening exercises to help ease it.
Opioid prescriptions have skyrocketed over the last 25 years. Originally they were intended for post surgical patients and those in the end stages of cancer. In 1991 there were around 76 million prescriptions but by 2013 that number had risen to almost 207 million prescriptions.
There are strong ties in rises of opioid use and heroin use.
As prescriptions have risen, so have abuses. According to the CDC more than 1000 people a day are treated in emergency rooms for inappropriate opioid use. As many as 1 in 4 people using opioids long term struggle with addiction. In 2015 there were nearly 60,000 drug overdose deaths, nearly half of those were from opioid drugs and opioid prescriptions frequently lead to other narcotic abuse. The economic costs of opioid abuse is estimated to be$75 billion a year. On top of all of that, there is no research to suggest that the amount of opioids has had any impact on people suffering from chronic pain. Patients who take opioids for even 1 day have a 6% chance of using them a year later, a 13% chance if they are used more than 8 days and a 30% chance if they are used for a month.
This year the American College of Physicians updated its guidelines for the treatment of acute and chronic back pain to recommend first using non-invasive, non-drug treatments before resorting to drug therapies.
The Joint Commission (the organization that accredits hospitals) has also added chiropractic treatment to its pain management recommendations. The guidelines were published in the Annals of Internal Medicine and based on reviews of randomized controlled trials and observational studies, and recommend spinal manipulation, massage and therapeutic exercise as first treatments for low back pain. Multiple studies support manual therapies and exercise to both resolve acute and chronic pain, but also for conditions you might not expect to see a chiropractor or physical therapist for: Parkinson’s, balance disorders, arthritis, and many others.
Chiropractors and physical therapists have excellent patient satisfaction scores.
A typical treatment plan for a chiropractor or a physical therapist costs less than an MRI. Chiropractors and physical therapists are neuromusculoskeletal experts, and do far more than just pain relief, they create treatment plans that correct problems. You’ll be stronger, have better range of motion, and in general be more functional and be better able to do the things you love and your chance of recurrence will be lower. Do you have pain? Give us a call and see how we can help!
With the increase in technological devices of late, posture has been a recurring theme in physical health news more and more. You may have even heard the term “text neck”. If you’ve ever been to a physical therapist or a chiropractor you may have even heard more sophisticated terms like “Upper Cross Syndrome” and “Lower Cross Syndrome.” If you’ve been to Pilates, yoga or barre classes you’ve also probably heard about pelvic tilts and “tucking.”
We know that a good posture is healthy for us. But, you may be asking yourself – what exactly is good posture, and how can I maintain it?
Good posture looks like this.
Your ears should be in the middle of your shoulders – and your shoulders directly over your hips – and all of that in-line directly over your ankles. Be sure and keep your shoulders down and back, too – not rounded forward. When you’re in a good posture position, you should notice:
- Your spine should make a gentle ‘S’ curve.
- Your pelvis should be level and your weight should be evenly distributed through your feet.
- You experience no pinching in your lower back.
- You feel no discomfort or excess weight in your heels or the balls of your feet.
The affects of not maintaining correct posture can be significant. Bad posture can lead to pain, injury and even degeneration of the spine. So, take heed and be mindful of your posture in during everyday activities – including how you are holding your head and neck while texting.
Stay tuned for more in our series on posture – the positive, and negative, affects it can have on your health.
Sleep is important. Yet, despite our awareness of sleep benefits, we often don’t make getting enough of it a priority. Sleep loss costs the U.S. $4.2 billion dollars a year – an equivalent of 1.2 million work days a year. But there is more to sleep than getting enough. How you sleep can be just as important to your health.
Many people sleep on their stomachs. And while stomach sleeping can help with snoring, it can also exacerbate and prolong neck and shoulder pain from a recent or recurring injury.
Side sleeping – with your arms below chest level – is better. But, also brings risk of waking with numbness and tingling in your arms from having them in the wrong spot. I recommend sleeping on your side with your arms down, and your legs almost straight, with a pillow between your knees. Many people have a tendency to bring their chin toward their chest in this position. Try to keep your neck straight, and be sure your pillow is thick enough to keep your spine straight. Side sleeping requires a thicker pillow than sleeping on your back.
So, what’s the best sleep position to cover by best?
As a chiropractor, I like back sleeping with your arms down best. It keeps your spine straight and level. This is the ideal position for back health and injury recovery. Tucking a pillow below underneath your knees can be a good extra measure as well. However, if you snore or have sleep apnea, this may not be the best position for you.