The Smart way to Manage your Low Back Pain - without blowing the budget!

If you are reading this because you are experiencing or have experienced low back pain then you may take some comfort in the fact that you are in the majority – not the minority. It is estimated that 70-90% of people will experience low back pain at some point in their life. The 2011/12 Australian Bureau of Statistics National Health Survey reported that 3 million Australians (13.6% 0f the population) were experiencing back problems. While there may be some comfort in this information it does not take your back pain away - so what should you do to manage your low back pain? There are many different health professionals/ therapists/ drugs that claim to treat low-back pain so how do you decide what path to take. Or should you just try everything? An important consideration is the financial costs associated with treatment and this can be quite substantial. For any treatment, particularly one that may hit your wallet/purse quite hard, it would be nice to know before committing to it whether it is likely to be effective in treating your back condition. There has been a lot of research in to the effectiveness of different treatments for low back pain, and guidelines established for the best management. The summary below will hopefully help you make an informed decision on how you are going to manage your condition.

On review of different International Guidelines for the management of back pain there are some consistent features that all seem to agree on1:
Acute back pain (within 4-6 weeks) sufferers should be encouraged in to early and gradual activation/movement; bed-rest is discouraged and any individual factors that may lead to the injury becoming chronic should be identified.
Chronic back pain (3+ months) responds to supervised exercises, education and behavioural changes to help the condition and a multi-disciplinary treatment approach to address the contributing factors. Despite wide variations in treatment patients seem to experience broadly similar outcomes although the cost of treatment can vary substantially2. So costs associated with treatment should be an important factor when deciding your treatment provider. Beyond cost, here is what the research suggests your care provider should employ in your management:
Acute Back Pain

• Patients should be reassured of a favourable prognosis, advised to stay active, use of medication if needed, bed-rest is discouraged and there is no need for a supervised exercise program1.

• Imaging or other diagnostic tests should not be routinely performed unless a more serious injury is suspected2.

• You should be provided with information on your injury, the expected course it will run and be provided with effective self-care options2.

• If medication is required then for most patients first line medications are simple paracetamol or Non-Steroidal Anti-Inflammatories2.

• Manual therapy/ mobilisations can provide small to moderate short-term benefits2.

• Exercise therapy is as effective as other conservative treatments and there appears to be no additional benefit to spinal manipulative therapy than other recommended therapies2.

 In summary, if your treatment provider can provide you with good information and advice regarding self-management strategies and prescribes exercises you can easily perform yourself then you should make a good recovery without having to fork out lots of money. If you find manual therapy helps your pain levels you may decide to receive this treatment as your pain settles.

Chronic Back Pain

• The use of modalities (therapeutic ultrasound, electrotherapy) should be discouraged and short-term use of medication may be beneficial1.

• You should be performing a supervised exercise therapy1.

• All contributing factors (physical and non-physical) should be identified and appropriately addressed through multi-disciplinary treatment1.

• Self-care is important, including advice on staying active and education about your condition2,3.

• Medications may be required and non-pharmacological treatments that have shown effectiveness in treating chronic back pain include manipulative therapy (manipulations/mobilisations); exercise therapy; massage; acupuncture; yoga; cognitive behavioural therapy; progressive relaxation or multi-disciplinary approach involving a selection of the above2.

• Exercise therapy has an effect in reducing pain and improving function4. Programs incorporating individual tailoring, supervision and a combination of stretching and strengthening are associated with the best outcomes1.

• Massage is more likely to be beneficial when combined with exercises and education and pressure point massage appears to offer more relief than traditional Swedish7.

• Spinal manipulative therapy (manipulation or mobilisation) appears as effective (no better or worse) than other existing therapies6.

Again an active approach is important when managing chronic low back pain. It appears some form of appropriate supervised exercise program that has been tailored to your presentation is important and may be complimented by appropriate manual treatment such as massage, mobilisation and/or manipulation or acupuncture. Again cost-effectiveness is important when deciding upon your treatment provider/providers so you should consider whether a provider offers a suitable combination of the above treatments.

There are many options available for treating your back pain. Hopefully the summary above helps you make a more informed choice when deciding your treatment approach.

Stuart McKay
APA Physiotherapist

1. Koes BW, van Tulder M, Lin CC, Macedo, LG, McAuley J, & Maher, C (2010) An updated overview of clinical guidelines for the management of non-specific low back pain in primary care. Eur Spine J 19: 2075-2094
2. Chou R, Qaseem A, Snow V, Casey D, Cross Jr T, Shekelle P & Owens DK (2007) Diagnosis and Treatment of Low Back Pain: A joint clinical practice guideline from the American College of Physicians and the American Pain Society. Ann Intern Med. 147: 478-491
3. National Institute for Health and Care Excellence (NICE) Clinical guideline 88 (2009). Low Back Pain: Early management of persistent non-specific low back pain (guidance.nice.org.uk/cg88).
4. Hayden J, van Tulder MW, Malmivaara A & Koes, BW (2005) Exercise therapy for treatment of non-specific low back pain (Review). The Cochrane Library 2005, Issue 3
5. Rubinstein SM, Terwee CB, Assendelft WJJ, de Boer MR, van Tulder MW (2012) Spinal manipulative therapy for acute low-back pain (Review). The Cochrane Library 2012, Issue 9
6. Rubinstein SM, van Middelkoop M, Assendelft WJJ, de Boer MR & van Tulder MW (2011) Spinal manipulative therapy for chronic low-back pain (Review). The Cochrane Library 2011, Issue 2
7. Furlan AD, Imamura M, Dryden T & Irvin E (2008) Massage for low-back pain (Review). The Cochrane Library 2008, Issue 4

ACCELERATED ANTERIOR CRUCIATE LIGAMENT REHABILITATION PROGRAM

Eastern Suburbs Sports Medicine Centre

& Eastside Physiotherapy

ACCELERATED ANTERIOR CRUCIATE LIGAMENT REHABILITATION PROGRAM (Hamstring graft)

Alan Davies & Diane Long (APA Sports Physiotherapists)

The following ACL reconstruction rehabilitation program is our current regime and is based upon current clinical information regarding open and closed chain exercise, early mobilisation, progressive controlled loading of the knee joint and years of experience in returning people back to their previous level of sport or recreation. 

The time frame stated in this program should be flexible and act only as a guide.  Progression should be based on an individual basis.  Factors that may influence expectations of progression include the patient’s age, their attitude to exercise, associated pathology including meniscal, chondral and other ligamentous damage. 

STAGE ONE - ACUTE POST OP

Time Frame 0-2 weeks

Goals

1.  Wound healing (sutures removed approximately day 10).

2.  Reduce post operative pain and swelling.

3.  Regain full extension.

4.  Full weight bearing.

5.  Wean off crutches and normalise gait.

6.  Promote muscle control.

Treatment Guidelines

1.  Pain and swelling reduction with ice, intermittent pressure pump, soft tissue massage and exercise.

2.  Patella mobilisation.

3.  Active range of motion of the knee joint, calf and gentle hamstring stretching, co-contraction (non weight bearing progressing to standing) to aid in re-gaining range of movement, muscle control and full weight bearing.  Aim for full extension within two weeks.  Full flexion will takelonger and will generally steadily improve without the effort of focal heavy stretching.

4.  Gait retraining encouraging extension at heel strike.  Full weight bearing is encouraged.

Nb.  As hamstring strains and pain are common in the first six weeks, care needs to be taken with the intensity of hamstring activation on co-contraction exercises.  Over emphasis of hamstring contraction may lead to hamstring strain at this stage.  Light hamstring loading continues into the next stage with progression of general rehabilitation.  Resisted hamstring loading should be avoided until approximately week six.

STAGE TWO - QUADRICEPS CONTROL

Time frame - 2-6 weeks approx.

Goals

1.  Full active range of movement

2.  Normal gait with reasonable weight bearing and walking tolerance

3.  Minimal pain and effusion

4.  Develop muscular control for a controlled pain free single leg lunge

5.  Avoid hamstring strain

6.  Develop early proprioceptive awareness

Treatment Guidelines

1.  Use active, passive and hands on techniques to promote full range of movement.

2.  Progress closed chain exercise (quarter squats and single leg lunge) as pain allows.  The emphasis is on pain free loading, VMO and gluteal activation. 

3.  Introduce gym based exercise equipment including leg press and stationary cycle. 

4.  Once the wounds have healed water based exercise can begin.  This can include wading, bicycle action in the water, simple range of motion and gentle swimming (no breaststroke).

5.  Begin proprioception exercises including single standing leg balance on the ground and on the mini-tramp.  This can be progressed by introducing body movement whilst standing on one leg and including wobble board. 

6.  Develop a calf strengthening routine including bilateral calf raise progressing to single calf raise and stretching. 

7.  Refrain from isolated loading of the hamstrings (due to ease of tear).  Hamstrings will be progressively loaded through closed chain and also gym based activity during this stage. 

STAGE THREE - HAMSTRING/QUADRICEPS STRENGTHENING

Time Frame - 6-12 weeks

Goals

1.  To begin specific hamstring loading.

2.  Increase total leg strength.

3.  Promote good quadriceps control in lunge and hopping activity in preparation for running.

Treatment Guidelines

1.  Focal hamstring loading begins and is progressed steadily throughout the next stages of rehabilitation.

a. Active prone knee flexion which can be quickly progressed to include a light weight and then gradually progressed by increasing the weight.

b.  Bilateral bridging off a chair.  This can be progressed by moving onto a single leg bridge and then single leg bridge with weight held across the abdomen.

c.  Single straight leg dead lift (single bend over)  initially active and then can be mademore difficult by adding weights. 

Key points with hamstring loading are  that to never pushed into pain and volumes and intensities are carefully progressed.  Any minor setback of subtle strain or tightness post exercise should be managed with a downgrading of hamstring based exercises. 

2.  Gym based activity including leg press, light squats and stationery bike can be progressively increased in intensity as pain and control allow.  A key point is to monitor effusion post exercise.  Any effusion that is exacerbated with exercise should signal a reduction of training intensity. 

Once single leg lunge control is good comparable to the other side hopping can be introduced.  Hops can be made more difficulty by including variation such as forwards/back, side to side off a step and in a quadrant.

4.  Running may begin towards the latter part of this stage.  Certain criteria must be met prior to the onset of running.

These include:

            a.  No anterior knee pain.

            b.  A pain free lunge and hop that is comparable in control to the other side.

            c.  The knee also must have no effusion. 

            d. Good control on single hop painfree

             e. Good tolerance to distance walking.

Jogging should begin with a walk/jog.  Ideally, this is done on a treadmill to monitor landing action and also to carefully monitor effusion post exercise.  Again, any increase in effusion following jogging should be met in a reduction in training intensity.  Walk/jogging should be attempted for 2-3 times per week for 1-2 weeks before progressing onto jogging alone.

5.  Proprioception exercises are made more difficult with more aggressive manoeuvres in standing leg balance, wobble board and also by progressing hopping based activity. 

6.  Expand calf routine to include eccentric loading.

STAGE FOUR - SPORTS SPECIFIC

Time Frame - 3-6 months

Goals

1.  Increase total leg strength.

2.  Develop running endurance speed, change of direction.

3.  Advanced proprioception.

4.  Neuromuscular training, developing good landing mechanism on jump and hop activity and PEP style activity

5.  Preparing for a return to sport and recreational lifestyle.

Treatment Guidelines

1.  These activities should build in intensity and volume over this time frame.  Controlled sport specific activities should be included in the progression of running and gym loads through this time frame.  Increasing effusion post running that isn’t easily managed with ice should result in a reduction of running loads. 

2.  Advancing neuromuscular and proprioception to include controlled hopping, jumping and landing (soft landing with adequate knee flexion and ankle dorsiflexion and good knee in line with toe alignment) , running with change of direction and balance correction.  

3.  Continue to increase intensity with training loads of gym based exercise program. 

4.  Monitor potential problems associated with increasing loads.

5.  No open chain resisted leg extension unless authorised by your surgeon.

STAGE FIVE - RETURN TO SPORT

Time Frame - 6 months plus

Goals

1.  A safe return to sport and normal recreational lifestyle.

Treatment Guidelines

1.     Full training for 1 month prior to active return to competitive sport.

2.  Preparation for body contact sports.  Begin with low intensity one on one contests and progress by increasing intensity and complexity in preparation for drills that one might be expected to do at training.

3.  To develop running endurance as to be able to handle a normal training session.

4.  Full range, no effusion, good quadriceps control for lunge, hopping and hop and turn type activity.  Strength estimates to within 10% of other side on multiple testing involving quads, hamstrings and calves.

5. Single leg hop and multiple hops for distance within 10% of other side

6. PEP and FIFA 11+ are examples of programs that have been shown to reduce ACL injury rates. These kinds of programs or variants with sport specific additions should be incorporated into warm ups longer term to reduce risk of recurrence. Australian Netball have produced an excellent version of this that is netball specific

7. Psychological readiness for return to sport comes with thorough late stage rehabilitation. ACL-RSI is a useful measurement tool (App or online) to determine psychological readiness

8. Reinjury rates are higher in reconstruction patients under 18 years old and also in those returning to sport inside of 12 months post op. Consideration should be given to holding back return to sport in this group however this may depend on individual circumstances and how high risk the sport is in managing return to sport

POTENTIAL PROBLEMS

1.  Infection.  The patient may complain in the acute post op period of significantly increased pain (constant throbbing in nature), fever and be generally unwell.  The knee may present with increased swelling and demonstrate heat.  The surgeon should be contacted immediately.

2.  Deep venous thrombosis.  Increased swelling, tenderness to palpation and pain particularly in the calf may be signs of a DVT.  Again, this should be assessed immediately by the surgeon. 

3.  Functional instability.  Poor quadriceps control and too early removal of crutch usage may result in the patient feeling that their knee gives way or feels unstable.  This is not related to a structural instability but rather a lack of quadriceps control due to pain and swelling associated with the surgery. 

4.  Hamstring strain and pain.  As hamstring tendons (semi-tendinosis and gracilis) are utilised as a graft donor site, hamstring soreness is typical in the acute post op period.  Over zealous rehabilitation and daily activity can lead to hamstring strain which can delay progression and require modification of rehabilitation. 

5.  Poor range of motion.  Current surgical techniques usually allow for relatively quick restoration to full range of movement.  Fortunately, arthrofibrosis is quite rare.  Delaying surgery for several weeks following initial injury can reduce the risk of arthrofibrosis.  Regaining full extension and muscle control in end range of extension is a priority early in rehabilitation.  This is essential in the restoration of a normal gait.  Exercise, calf and hamstring stretching, gentle extension stretches, soft tissue techniques and patella mobilisation will promote full extension.  Flexion will usually progress with rehabilitation and only require to be pushed in later stages if full flexion has not been restored. 

6.  Recurring effusion.  Persistent or recurring joint swelling may be a problem through the mid-late stages of rehabilitation.  Typically, it may happen in those patients who have had meniscal and/or chondral pathology or those who spend long periods in standing.  It is also common with significant progressions in running and training intensity.  Anti-inflammatory medication and ice following rehab can also be useful strategies to manage the persistent effusion.  A cautious approach to rehab and running progression is also essential. 

7.  Anterior knee pain.  This can be a problem at any stage through rehabilitation.  Poor VMO, too rapid progression of closed chain exercise, over zealous daily activity, abnormal gait (flexed knee at heel strike), too early return or too sudden progression of running loads may overload the patellofemoral joint and/or patella tendon and cause irritation. 

8.  Poor landing mechanism.  Patients with reduced quadriceps control on lunging and hopping activity (reduced knee flexion on landing) are not ready to resume running and doing so usually results in altered running action causing joint soreness and potentially patella tendonitis or patellofemoral pain. 

9.  Graft failure.  Graft failure can occur.  The risk of graft failure should not prevent a person from returning to their pre-injury level of sport or activity once full function of their knee is restored. 

Resources:
PEP Program
FIFA 11+ Program

Iliotibial Band Friction Syndrome (ITBFS)

Anatomy

The iliotibial band is a long connective tissue which begins up towards the hip (attaching to the gluteus muscles and another muscle called tensor fascia lata). It runs downwards, inserting onto a bony prominence on the outside of the knee (lateral epicondyle of femur). A bursa (a fluid filled sack) lies in between the bone and the ITB to reduce the amount of friction that can occur with activity.

Mechanism

Iliotibial Band Friction Syndrome (ITBFS) is an overuse condition that occurs over time. With repetitive bending (flexion) and straightening (extension) of the knee at small ranges, the ITB pulls on its attachment. This causes friction at its insertion on the bone and irritation of the bursa. Commonly, running (particularly downhill or on uneven surfaces) and cycling, both of which involve repeated knee flexion/extension can cause ITBFS. Weak hip abductors (including the gluteus muscles which help to move the leg outwards), or weak hip flexors (which move the knee towards the chest) have been linked to ITBFS. Other contributing factors include poor biomechanics, particularly foot pronation (where the foot rolls inwards), and a recent increase in training volume such as intensity and/or duration.

Symptoms

Pain is felt on the outside of the knee at the ITB attachment site and directly above on the outside of the thigh. This is often described as an ache which worsens during continued activity. Occasionally, a clicking noise can be heard due to the ITB flicking over its attachment with knee flexion and extension. Tightness along the ITB may also be felt.

Treatment/ Future implications

Treatment initially aims to reduce the inflammation within the bursa that has been irritated by friction of the ITB on its attachment. A period of resting from aggravating factors is needed to allow this inflammation to settle. Soft tissue massage throughout the ITB and muscles around the hip is often needed. Stretching of the ITB and strengthening of the hip muscles is usually indicated. Treatment can depend upon the cause of ITBFS; biomechanical abnormalities and training load should be addressed if these are contributing. With failure of conservative treatment or in severe cases, an injection within the bursa can help to settle the pain. Surgery may be needed to release the ITB and remove the bursa.

Anterior Cruciate Ligament (ACL) Injury

Anatomy

The anterior cruciate ligament (ACL) is a found within the knee joint. It attaches between the back of the femur (thigh bone) to the front of the tibia (one of the shin bones). This ligament helps to prevent movement of the tibia forward relative to the femur and controls rotation about the knee, such us during pivoting movements.

Mechanism

The common injury is an ACL rupture in which an isolated injury can occur, or may be combined with other knee injuries depending on the mechanism of injury. Risk factors include being female (up to 8 times greater risk), having a stronger firing pattern of the quadriceps relative to the hamstring muscle, preforming sporting activities involving landing from jumps or cutting maneuvers, and a previous ACL injury on the opposite leg.

Symptoms

Pain is felt immediately and is often combined with a “popping” noise. Depending on the extent of injury and whether or not other injuries have also occurred, pain is often general in location. However, due to the shearing of the tibia forward from the femur which tends to stretch the outer part of the knee joint capsule, there may be pain localised to the outside part of the knee. Difficulty occurs with continuing activity and it is common for swelling to develop within the hour around the knee. A feeling of giving way is frequently described after this type of injury.

Treatment/ Future Implications

Treatment strongly depends upon the patient and can either be conservative involving rehabilitation only, or surgery followed by rehabilitation. Factors to consider surgery over conservative include the severity of injury, age of the patient, and a patient’s sporting activities or goals. The time and cost of surgery and rehabilitation is another factor that must be considered. Surgery is a strong option for active people who want to return to sport which may involve a degree of intensity, pivoting movements, a change in direction, or direct contact. Three different surgery techniques are available (patella graft, hamstring graft and LARS) and again this depends upon the patient. An MRI confirms an injury that is often predicted clinically. However, this investigation also determines the extent of the injury and whether other structures have been damaged. Rehabilitation after surgery can take up to 12 months before return to sport occurs. However, this time frame is a gude only with some patients responding quicker. Osteoarthritis and a high re-injury rate on the opposite leg have been reported as risk factors after an initial ACL injury.

ROTATOR CUFF TENDINOPATHY

Anatomy
The rotator cuff muscles are a group of four muscles around the shoulder. They include the supraspinatus, infraspinatus, subscapularis and teres minor. The muscles have a specific role in FINE TUNING SHOULDER MOVEMENT, STABILISING AND WORKING IN CONCERT WITH LARGER MUSCLES TO CREATE STRENGTH in moving the shoulder particularly in rotating (twisting the arm in or out), and together they work to stabilise the shoulder within its socket. Each muscle is attached onto the shoulder bone via a tendon. A tendinopathy refers to REPEATED DAMAMAGE AND irritation of the tendon.

Mechanism
Rotator cuff tendinopathy is an overuse condition occurring from repetitive use of the rotator cuff muscleS. The supraspinatus muscle is the most common muscle, and therefore tendon, affected. rotating the arm. Injury can occur overtime from repetitive throwing sports such as water polo, or repetitive shoulder movements such as swimming. With continued use and contraction, the muscle’s tendon continues to become irritated at its attachment onto the bone. An inflammation response develops AND POTENTIALLY STRUCTURAL TENDON CHANGE RESULTING IN PAIN ON BOTH COMPRESSION AND TENSILE LOAD as a result of this irritation.

Symptoms
Pain develops gradually over time and is felt at the shoulder or can radiate down into the upper arm. Pain may be felt at the start of activity, warm up, then return once activity ceases. However, as the condition progresses, pain can be felt at the start of activity and worsen as the activity is continued. Pain is often worse at night, particularly when lying on the injured side. Commonly overhead activities or taking the arm out to the side are worse with a supraspinatus injury. However, pain and limitation is dependent upon which rotator cuff muscle is involved; pain may be felt when reaching behind the back (such as when putting a bra on putting a wallet in the back pocket). A pinching feeling in the shoulder can be felt as the rotator cuff muscles are not able to stabilise the shoulder within its socket as efficiently, resulting in impingement of the shoulder onto the surrounding structures.

ADHESIVE CAPSULITIS

Anatomy
The shoulder joint (glenohumeral joint) is surrounded by a capsule made up of connective tissue and ligaments within. Capsulitis refers to inflammation within this capsule causing scarring of the tissue. This then results in pain and restricted range of movement of the shoulder. The term “frozen shoulder” has its name from the limited range of movement that occurs.

Mechanism
Although there is no known cause for adhesive capsulitis, there are potential risk factors which include shoulder surgery, shoulder injury and diabetes. Commonly, the age group at risk is those over 40 years of age. There is also a higher incidence in females.

Symptoms
Adhesive capsulitis can be broken down in stages by the symptoms felt. In the first stage pain is felt, commonly with no known mechanism. In the second stage, stiffness of the shoulder and decreased range of movement occur over time secondary to a lack of movement from pain and the inflammation. All shoulder movement can be painful and/or stiff.

Treatment/ Future implications
Treatment often depends on the severity and the stage of adhesive capsulitis. Commonly, pain can be treated with anti-inflammatory medication. However, a steroid injection may be required for stronger pain relief. Soft tissue massage can improve range and limit symptoms, and is often used in conjunction with pain relief. Adhesive capsulitis can take up to 9 months for complete recovery if treatment is sought. Without treatment, the condition can resolve over a longer time and may take up to 2 years to recover. However, some loss motion may occur without seeking treatment. If little improvements do occur, surgery may be indicated.

PEP and FIFA 11+ Injury Prevention Programs

Below are links to two commonly used injury prevention programs and are commonly prescribed to patients during the final phase of ACL rehabilitation. The programmes consist of a warm-up, stretching, strengthening, plyometrics and sports specific agilities to address potential and coordination of stabilising muscles around the knee. These are suitable for athletes 14 years and older and must be completed with proper technique. Once familiar with the program it should take between 15-20 minutes to complete.

There is scientific evidence that a football team providing the FIFA 11+ program at least twice a week had 30-50% fewer injured players.

http://smsmf.org/smsf-programs/pep-program

http://f-marc.com/11plus/downloads/