Book an Appointment

 

 

Do I have a serious back problem?

Fortunately, most low back pain episodes fall under the category of non specific low back pain. As our previously blog post discussed there is a very good chance that you’ll experience back pain at some point in your life.

Some conditions can produce back pain that are more urgent to medically assess and treat. While statistically they don’t occur frequently, they fall into one of these categories:

 

Spinal Cord compression

In most people the spinal cord ends just above your low back. A group of peripheral nerves continue down through the rest of your spine known as the cauda equina for their resemblance to a horse’s tail. If either the spinal cord or the cauda equina are being compromised your symptoms will include:

  • Loss of sensation in your “saddle” the area that you wipe after going to the bathroom
  • A new change in your ability to hold in your feces or urine. Specifically, the inability to properly empty your bladder or a bowel and bladder that spontaneous empties when full without you being able to control it
  • Loss of sensation of both legs
  • Inability to control the muscles of your legs

 

Infections

Spinal infections are another potential serious source of low back pain. These symptoms will generally be associated with a fever and a history of infection. They are more common if you are immune compromised or use intravenous medication.

 

Cancer

Cancer of the spine can cause pain. The cancer can cause destruction of bone leading to bone pain. Cancer causing back pain can be ruled out if you’ve had no past medical history of cancer.  If you have had a history of cancer, are experiencing a new episode of low back, are experiencing a significant amount of unintended weight loss and pain that wakes you up at night, your doctor will refer you for an MRI to rule this out as a source of back pain. 

 

Fracture

If you are a healthy adult a spinal fracture requires significant traumatic force.  This can occur with a fall from a significant height or a motor vehicle accident.  If you have osteoporosis then large amount of forces are not required to fracture your spine.  In either of these cases your doctor will order an X-ray to rule out a fracture.

 

I don’t have those

Middle arrow of facet joint pointing to fracture of pars interarticularisThat’s a good thing! Just because you don’t have the above, or if they’ve been ruled out, it doesn’t minimize the back symptoms you have. The first step is to give back pain some time to improve. Try and keep moving as much as you are able to pain free. 

Most episodes of back pain will have a direction if preference. Some structures, like the spinal facet joints, when aggravated, become more painful when standing and feel better with sitting. Exercises such as biking would become a good way to maintain your fitness while respecting your pain.

Other areas like the muscles of the back, discs and ligaments often prefer positions of standing. Exercise that maintain back extension would be the best start and could include walking or swimming. 

 

Shouldn’t I get an MRI to see what’s going on?

Numerous studies have shown that in early stages, MRIs become important to rule out the above emergencies and urgent problems. The amount of “problems” found on X-Rays and MRIs increase as we age, but that doesn’t mean that these discovered problems are the source of your symptoms.  MRIs also become necessary if the worst pain is leg pain and not improving with conservative management. At that point an MRI will determine if you are a candidate for back surgery to take pressure off of the affected nerves.

Studies show that early imaging increases the number of surgeries performed but in the long term shows no benefit over those in a conservative treatment program.

 

I don’t want surgery but the pain isn’t going away

Video appointments are easy and can help you now with your pain

If your pain is continuing for more than 2 weeks then conservative management becomes the next strategy. With social distancing, this will likely involve a video consultation. If you’ve ever used the internet then you have the tools for a video consultation.

Your physiotherapist will take a detailed history to determine what factors may need to be addressed including past injuries and limitations. Various movement tests, nerve tests and joint tests can be performed without hands on touch to determine the best way to reduce your pain and get you back to normal. You will be taught exercises to reduce the pain and improve your function. 

During social distancing these sessions may be done online. A tailored program to address your pain, core strength and areas contributing to your symptoms will be prescribed.

 

 

 

Family Physiotherapy, assessing and treating persistent injuries and pains for the residents of Thornhill, Markham and Vaughan

The physiotherapists at Family Physiotherapy have been providing high quality assessment and treatment techniques using safe and evidence based techniques to the residents of Thornhill, Markham, Richmond Hill, Woodbridge, Vaughan and Toronto. Our therapists are continually upgrading their skills and take the time to provide you with the one on one care necessary to quickly get you back to the activities you love doing.  Comprehensive assessment and treatment techniques are always one on one without the use of assistants or double booking patients to make sure that you achieve your functional and sports goals as soon as possible.  Our therapists would be happy to help you to achieve your goals, contact the clinic to schedule a consultation to get you back on track.  Don’t let pain ruin your day!

 

 

References

Chou R. et al. “Diagnosis and Treatment of Low Back Pain: A joint Clinical Guideline from the American College of Physicians and the Pain Society” Annals of Internal Medicine 2007; 147: 478-91

Health Care Guideline: Adult Acute and Subacute Low Back Pain Institute for Clinical Systems Improvement January 2012 (15th ed.)

Jacobs W. et al “Surgery vs conservative management of sciatica due to a lumbar herniated disc: a systematic review” European Spine Journal 2011; 20: 513-22

 

Contact Us

Located in Thornhill we are conveniently located near Markham, Richmond Hill and North York.

2300 John Street Unit #7 Thornhill, Ontario

Contact Us Today

 

 

 

 

 

Functional Core

There’s more to the core than just the deep muscles of the spine. Our previous blog post discussed the inner unit muscles and the role they play on spinal stability. But is that all that you need?

Functionally, there are more muscles involved in controlling our movements and improving our sports enjoyment and day to day activities. These additional muscles involve local muscles of the trunk and those connecting the trunk to the limbs.

 

How do the superficial muscles help me?

A commonly used example that the exercise kinesiologist Dr. Stuart McGill uses is comparing your spine to a fishing rod.  Imagine that you’re trying to make this fishing rod stand up on its end. If you let go, the rod will fall over because there’s nothing to support it. If you wanted to make it stand on end, you could use ropes tied from the tip of the fishing rod to the dock below.

If you were to do this, where would you attach them?

If the ropes were very close to the base of the fishing rod they wouldn’t provide very much stability. You would want ropes that attach further out.

 

The big 3 core exercises

Similarly, by themselves the deep inner unit muscles are not sufficient to support our spine during functional movements. For our spines, the larger ropes attaching further away are the more superficial muscles of our trunk. They include your abdominal muscles (internal obliques, external obliques and rectus abdominus) and your quadratus lumborum muscles.  Dr. McGill is a proponent of the big 3 exercises to train the outer core. These exercises are:

  1. Sideplank
  2. Bird dog
  3. Curl-up

 

Side Plank

 

The beginner side plank or side bridge starts with the hips in a neutral position with the knees bent to 90 degrees.  The object of the exercise is to raise your hip and thigh up on the support of your knee and elbow.  Though this is a beginner exercise, if these muscles are deconditioned you may find that you cannot raise up.  Alternatively, you may find that you experience discomfort in your neck or shoulder.  There are modifications that your therapist may prescribe to ensure that this exercise is right for you. 

Progressions may include performing arm or leg movements during this task or progressing you to straightening one or both knees.

 

Bird Dog

The bird dog can be a more challenging exercise engaging your hamstrings and gluteus maximus muscles in addition to the lumbar erector spinae. One of the biggest challenges of this exercise is ensuring that you’re starting in a neutral spine position. If a stick is placed along your back, it should be touching your sacrum, midback and the back of your head.

 

While performing the full version of the exercise you will require sufficient control of rotational forces trying to pull you out of position. If you find yourself falling over or unable to hold the position the exercise can be modified in a number of ways. This may include:

  1. Sliding a limb without losing contact with the ground
  2. Lifting only one limb at a time 
  3. Using an exercise ball under your abdomen to assist with proprioception and to take some of your body weight

 

Curl-up

The curl-up exercise is meant to engage the rectus abdominus muscle.  Unlike crunches, the goal is not to perform large amplitude movements of the spine.  Emphasis is placed on maintaining neutral spine posture during the exercise and bracing the abdominal wall.

 

How would I know if these exercises are right for me?

These larger core muscles play an important role in supporting our spines in neutral postures during day to day and in higher level activities. Painful movements during day to day activities can be in part related to poor control of spinal movement resulting in excessive flexion or extension of your spine.  Proper activation of these muscles will allow you to keep a neutral and supported spine whether you’re getting up from a chair, carrying the groceries in one arm or while you’re at the squat rack in the gym.

 

Why can’t I do these exercises properly?

Chronic postures at home and work, sedentary lifestyles and previous injuries are all factors in how you progress with these exercises.  In some cases the first symptoms are stiffness with attempts to increase your performance in sports or performing activities that you don’t normally do. Ignoring the problem doesn’t resolve it and can lead to future problems that are more difficult to treat.

 

Which are the right exercises for me?

If you’re recovering from low back pain, the first step is to get an appropriate assessment by a physiotherapist experienced in treating spinal conditions is key. Part of the assessment should include ruling out more serious problems that may need further investigation. During the assessment, your physiotherapist will check your strength, neurological system and patterns of movement; for example, they may use different cues to elicit movements that produce or alleviate your symptoms. This is done to piece together an individualized program tailored to your needs.

 

Image result for emoticon phone

Image result for emoticon email

 

Family Physiotherapy, assessing and treating persistent injuries and pains for the residents of Thornhill, Markham and Vaughan

The physiotherapists at Family Physiotherapy have been providing high quality assessment and treatment techniques using safe and evidence based techniques to the residents of Thornhill, Markham, Richmond Hill, Woodbridge, Vaughan and Toronto. Our therapists are continually upgrading their skills and take the time to provide you with the one on one care necessary to quickly get you back to the activities you love doing.  Comprehensive assessment and treatment techniques are always one on one without the use of assistants or double booking patients to make sure that you achieve your functional and sports goals as soon as possible.  Our therapists would be happy to help you to achieve your goals, contact the clinic to schedule a consultation to get you back on track.  Don’t let pain ruin your day!

 

Contact Us

Located in Thornhill we are conveniently located near Markham, Richmond Hill and North York.

2300 John Street Unit #7 Thornhill, Ontario

Contact Us Today

 

 

 

 

 

What are Spondylolysis and Spondylolisthesis?

Middle arrow of facet joint pointing to fracture of pars interarticularisSpondylolysis is a primary stress fracture of the pars interarticularis of the vertebral arch.  In the image to the right, this region is seen as the middle arrow of the facet joint region. The fifth and fourth lumbar vertebra are most often involved.  The defect itself can occur on one or both sides of the vertebra. When it occurs on both sides, the angle of the sacral base can promote a forward slippage of the vertebra, resulting in a spondylolisthesis. In an average population, the incidence of spondylolisthesis can be as high as 11.5% (Kalichman 2009).  Among an athletic adolescent population with low back pain, the incidence of spondylolysis was found to be as high as 47% (Micheli 1994).

 

Subtypes of Spondylolisthesis

Spodylolisthesis can be further classified according to it’s type.  5 subtypes are often described.

Type I: Dysplastic Spondylolisthesis

Dysplastic spondylolisthesis is a congenital lesion of the sacral base or the L5.  These abnormal congenital changes don’t provide resistance to forward shearing of the vertebra.

 

Type II: Isthmic Spondylolisthesis

Isthmic spondylolisthesis develops due to a defect in the pars interarticularis. This subtype is typically caused by a fatigue fracture of the pars interarticularis and are usually seen between the ages of 5 and 50.

 

Type III: Degenerative Spondylolisthesis

The degenerative type of spondylolisthesis occurs in response to long standing intersegmental instability. Due to their degenerative nature, this type is rarely seen under the age of 50.

 

Type IV: Traumatic Spondylolisthesis

Traumatic type spondylolisthesis occurs due to an acute fracture of a structure other than the pars interarticularis.  This type of spondylolisthesis is almost always due to a severe trauma.

 

Type V: Pathological Spondylolisthesis

In the case of pathological spondylolisthesis, integrity of the verterbra has been compromised due to a local or generalized bone disease.

 

Classification of Spondylolisthesis

Spondylolisthesis is commonly classified according to the Meyerding scale.  This scale describes the percentage migration of the upper vertebra on the lower vertebra.

  • Grade 1: Translation less than 25%
  • Grade 2: Translation between 26% – 50%
  • Grade 3: Translation between 51% – 75%
  • Grade 4: Translation between 76% – 100%

 

Do you have Spondylolisthesis?

Most patients with spondylolisthesis will complain of low back pain, much like other sources of back pain that were discussed in a previous blog post.  Nerve symptoms may also be present, which your physiotherapist should check for during the initial consultation.  Your symptoms will often worsen throughout the day and with severe stenosis there may be reports of changes in bowel and bladder function.  Leg symptoms may be present and will typically reduce with rest or flexed spinal postures.  These nerve symptoms may affect one or both sides.

Moeller et al showed that the incidence of symptoms in a spondylolisthesis population were:

  • Low back pain with sciatica 62%
  • Low back pain only 31%
  • Sciatica only 7%
  • 68% lumbosacral tenderness
  • Reduced lateral bending 46%
  • Hamstring tightness 22%

 

What is the Treatment for Spondylolisthesis?

Conservative management for spondylolysis and spondylolisthesis is the primary treatment strategy before surgical options are considered.  One qualitative meta-analysis of children and young adults with non surgical management of spondylosis and spondylolisthesis suggested 83.9% of patients treated non-operatively showed a successful clinical outcome after at least 1 year (Klein 2009). Physiotherapy interventions have been shown to be moderately effective in the treatment of low-grade spondylolisthesis (McNeely 2003). Specific treatment protocols have included:

  • The use of spinal flexion exercises being more beneficial on pain reduction as compared with extension exercises (Sinaki 1989)
  • Abdominal strengthening exercises in the absence of neurological or autonomic involvement (McNeely 2003)
  • Specific segmental training of the transversus abdominus and co-activation of transversus abdominus with segmental lumbar multifidus with progression to limb loading strategies and functional positions (O’Sullivan 1997)
  • General strengthening, stretching and motor control exercises (Hardwick 2012)

 

What Should I do?

The first step in conservative management should be to get an appropriate assessment by a physiotherapist with the training and experience to assess your symptoms.  This includes a thorough and detailed history of your symptoms, measures to determine nerve involvement and assessment of muscle strength to develop an appropriate treatment plan for you.  Treatment may include manual therapy techniques to improve movement of neighbouring stiff regions, core exercises to improve and reduce your symptoms and education on management strategies.

 

Not Sure Where to Start?

Our team of physiotherapists and massage therapists have training and experience to thoroughly assess your symptoms.  We can help you get you get your back symptoms under control.  Call or email us for more information!

 

Image result for emoticon phone

Image result for emoticon email

 

References:

Hardwick D, Tierney D, Fein C, Reinmann S, Donaldson M. Outcomes of strengthening approaches in the treatment of low-grade spondylolisthesis.  Physical Therapy Reviews 2012; 17(5): 284-91

Kalichman L, Kim DH, Li L, Guermazi A, Berkin V, Hunter DJ. Spondylolysis and Spondylolisthesis Prevalence and Association with Low Back Pain in the Adult Community-Based Population.  Spine. 2009 34(2):199–205

Klein G, Mehlman CT, McCarty M. Nonoperative Treatment of Spondylolysis and Grade I Spondylolisthesis in Children and Young Adults A Meta-analysis of Observational Studies. Journal of Pediatric Orthopedics. 2009; 29(2):146-56

McNeely ML, Torrance G, Magee DJ. A systematic review of physiotherapy for spondylolysis and spondylolisthesis.  Manual Therapy 2003; 8(2): 80-91

Micheli L, Wood R. Back pain in young athletes: significant differences from adults in causes and pattern.  Archives of Pediatric Adolescent Medicine 1995; 149(1): 15-18

Moller H, Sundin A, Hedlund R. Symptoms, Signs and Functional Disability in Adult Spondylolisthesis.  Spine 2000; 25(6): 683-9

O’Sullivan PB, Twomey LT, Allison GT. Evaluation of specific stabilization exercises in the treatment of chronic low back pain with radiological diagnosis of spondylolysis or spondylolisthesis. Spine, 1997; 22(24): 2959-67

Sinaki M, Lutness MP, Duane D, M. Ilstrup M, Chu CP, Gramse RR. Lumbar Spondylolisthesis: Retrospective Comparison and Three-Year Follow-Up of Two Conservative Treatment Programs.  Archives of Physical Medicine and Rehabilitation.  1989; 70: 594-98

 

Contact Us

Located in Thornhill we are conveniently located near Markham, Richmond Hill and North York.

2300 John Street Unit #7 Thornhill, Ontario

Contact Us Today

 

 

 

 

 

Book an Appointment

 

Low back pain

Incidence of low back pain

Low back pain is a common complaint.  A recent study has shown that the incidence of low back pain in the population ranges from 38% to 70% of an adult population.

Anatomy of the low back

The low back typically refers to the joints and tissues of the lumbar spine. This area represents the bottom 5 spinal vertebra (bones) between the thoracic spine and the sacrum (triangular bone in the pelvis). The vertebra are connected by the intervertebral discs. The back side of the vertebra are connected by symmetrical joints on either side, which are known as the zygoapophyseal (z-joints or facet joints more commonly).   A good analogy is to think of a tricycle.  The front tire represents the bone and disc while the back tires represent the joints.

Between the bones of the spine there are situated many ligaments that guide and restrict movements.  Further control of movement occurs actively through the coordinated contraction of the trunk muscles, in some cases before movement has occurred.  These muscles include some of the muscles of the abdominals and the muscles of the back more commonly known as the paraspinal muscles.

Between the bones of the back there are also nerve roots that exit to supply the muscles and tissues of the low back, hips, legs and feet.

 

What is the source of low back pain

There can be numerous causes of low back pain.

Low back pain from muscle strains

One of the most common sources of low back pain is local pain from one of the many muscles of the low back or muscles that refer pain to the low back.  The pain may have been caused by one activity such as occurs when lifting a heavy object or may have occurred after doing a repetitive task such or playing a sport.  Muscle pain is generally felt when the muscles are either contracted or stretched.

Low back pain from Nerves

Neurogenic pain refers to a pain due to an injury to the nerve or nervous system of the low back.  The pain can often be described as electrical and may shoot or jump to a different area.  Significant compression of a nerve root can result in the loss of sensation to further away regions of the body including the leg or foot.  If the nerve root supplies the muscles of the leg then one of the symptoms may include a giving out of the muscles when stress is placed on the nerve.  The affected area can be further away from the source of pain is generally felt when pressure is put on the nerve with standing postures, twisting or in some cases with prolonged sitting or stretching.

Low back pain from the Facet Joint

Pain symptoms elicited from the joints of the spine is commonly known as facet pain.  The pain often is at the low back but can radiate to the back of the thighs as well.  Postures that create compression of the region can elicit symptoms, this can be as extreme as carrying heavy weight on the shoulders or as mild as standing upright for long periods of time.  This area is often negatively affected by restrictions of movement in the shoulders, hips and knees.  The common position of ease is typically sitting down or leaning on the arms.  There is often an associated muscle weakness of the hip which is often felt when getting out of a chair.

 

Low back pain from the Disc

The lumbar disc provides restraints to excessive amounts of bending and twisting.  In younger spines the disc has a high water content and is vulnerable to injuries that involve sustained bending of the spine with or without twisting.  Injures to discs are often described as herniations or protrusions.  If the injury is large enough there can be pressure placed on the exiting nerve root which can result in nerve pain radiating into the low back and different parts of the leg.  Symptoms usually worsen in bent forward positions which can include sustained sitting.  With irritation of disc pain pain often radiates, or peripheralizes, away from the injured structure.  Often people with disc pain need to stand up to make the pain reduce.  This is often felt as a reduction of peripheral symptoms making you more aware of pain at the injured disc.  This phenomenon is know as centralization of pain and needs to occur for the disc to heal.

 

Other causes of low back pain

  • Soft tissue strains due to poor posture and muscle imbalances
  • Spondylolysis and spondylolisthesis
  • Trauma to the tissues or joints
  • Bone pain from loss of bone density
  • Joint pain from abnormal loading of the joint
  • Organ pain referral to the low back such as occurs with kidney stones
  • Emotional or psychogenic pain

 

Risk factors for low back pain

Some episodes of low back can’t be avoided.  However there are some factors that can increase your likelihood of having an episode of low back pain.  In one study these were found to include:

  • limping during the first few steps
  • hip/knee pain during sitting
  • overall widespread pain were associated with the first incident low back pain
  • having had a prior low back pain
  • having another current other musculoskeletal complaints
  • Men and women with prior low back pain were more inclined to report incident low back pain
  • Individuals older than 70 years with strength that was more than 50% within the same population

What can be done about low back pain

Manual therapy for low back pain
Family physiotherapy serving Markham and Thornhill

 

 

 

 

 

If you are experiencing low back pain the first step is identifying how to reduce your pain.  In some cases you will instinctively move or adopt positions to reduce the pain, but if there are multiple causes of low back pain then the easing position is not always apparent.  Often professional advice by on the proper way to move or sustain a position of the spine will help to reduce the pain that you are experiencing.  This should be done by a physiotherapist with training in spinal pain and conditions.  Part of the assessment by your physiotherapist should include a detailed history including previous injuries and medical condition, changes in activity or office setup in the months preceding the pain.  Often a series of movements of the spine can be given to help to continue to reduce the pain that you are experiencing.  For most low back pain a comprehensive physiotherapy assessment will be able to determine the cause and appropriate treatment for pain.  In most cases X-Rays and MRIs are not required unless back pain symptoms have been resistant to appropriate conservative treatment including core retraining and a flexibility program.

As your symptoms reduce in intensity the next step becomes to identify areas of restricted mobility, strength or poor posture that may have led to the development of the pain in the first place.  These can include simple body weight or weighted exercises or may involve flexibility or ergonomic advice.  If your goal is to return to sport or higher level activities there should be a transition to more sport related exercises and flexibility programs.

 

Prehab for low back pain

Muscle imbalances, lost mobility and strength deficits are most easily addressed and at a much lower cost if you are not currently in pain.  The proactive approach is to check out your problem areas before your next flare-up hits.  Don’t limit your daily routines and activities because of past pain.  

 

Related Posts:

 

Not Sure Where to Start?

Our team of physiotherapists, massage therapists and naturopathic doctors have training and experience to help get you get your symptoms under control and to prevent recurrence.  Call or email us for more information!

 

 

Family Physiotherapy, assessing and treating sports injuries for the residents of Thornhill, Markham and Vaughan

 

The physiotherapists at Family Physiotherapy have been providing high quality assessment and treatment techniques using safe and evidence based techniques to the residents of Thornhill, Markham, Richmond Hill, Woodbridge, Vaughan and Toronto. Our therapists are continually upgrading their skills and take the time to provide you with the one on one care necessary to quickly get you back to the activities you love doing.  Comprehensive assessment and treatment techniques are always one on one without the use of assistants or double booking patients to make sure that you achieve your functional and sports goals as soon as possible.  Our therapists would be happy to help you to achieve your goals, call the clinic to schedule a consultation to get you back on track.  Don’t let pain ruin your day!

 

 

Contact Us

Located in Thornhill we are conveniently located near Markham, Richmond Hill and North York.

2300 John Street Unit #7 Thornhill, Ontario

Contact Us Today