A lot of discussion surrounding back pain and biomechanics!

BUT….

A whole lot more to consider here beyond anything mechanical so a thread is in order 🧵🧵

This was highlighted nicely by @JanHartvigsen at al in the Lancet as a starter

thelancet.com/series/low-bac…
Co-morbidity affects back pain.

Here in older adults the number present predicted both pain and disability at 6 & 12 months

I suspect that this may not be adjusted by your biomechanics 😳

pubmed.ncbi.nlm.nih.gov/37937986/

As we know, exercise/movement for painful problems does not follow the same rules as exercise for fitness

Good news is there are other approaches that focus more on problems associated with MSK pain & often involve a GRADED approach

Here is a 🧵

1/ First up is graded exposure, this is a very well used but not always well understood term/process

Graded exposure is a psychological based therapy that looks to reduce fear and anxiety. It involves repeated exposure to a feared stimulus.



2/ncbi.nlm.nih.gov/pmc/articles/P…

A common phrase I hear in rehab is “individualising” exercise programs

It is often believed that this means the sets & reps or the specifics of a program

Maybe, it should relate more to the PERSON….But how?

Follow this 🧵 to learn more

1/10 GOAL/OUTCOME

How does THIS program achieve THIS persons specific goal?

That doesn’t mean it needs to LOOK like a movement, but it does have to relate to it socially, psychologically or physically in some way.

Not just a random exercise

2/10

Pain self efficacy (PSE)

PSE is the ability to function WITH or DESPITE some pain. This could be work, social or family related.

PSE is not a magic bullet, but might be part of recovery for some, or even many!

Here is a 🧵 "Pain self-efficacy refers to one's confidence regarding one's ability to function effectively while in pain"

pubmed.ncbi.nlm.nih.gov/16446108/

Do people with lower back pain move differently to people without back pain?

Well it turns out they do!

Check this 🧵to see the data & also if we need to change movement to help back pain..... Pain seems to change movement across the body

⬇️ Movement
⬆️ Stiffness
⬇️ Variability
➡️ Load distribution

Moving differently in pain: A new theory to explain the adaptation to pain

journals.lww.com/pain/Citation/…

2/

What's the BEST exercise for BACK PAIN?

Well it seems everyone has an opinion, but what does the evidence actually say?

Let's take a dive into the data!

Here is a thread 🧵 This one gets straight to the point

"Some types of exercise are more effective than others in people with chronic low back pain: a network meta-analysis"

They found PILATES to be the most effective in their network met analysis!

pubmed.ncbi.nlm.nih.gov/34538747/

2/

How does movement & exercise actually help pain? As it turns out there are a whole bunch of potential reasons why!

It's probably not the reasons many might think!

Let's take a dive into them, follow the the 🧵 for SCIENCE!

1/ Exercise decreases excitability and improves inhibition in both the central nervous system & immune system!

pubmed.ncbi.nlm.nih.gov/30113953/

Self-report greater levels of vigorous physical activity exhibit enhanced descending pain modulatory function

ncbi.nlm.nih.gov/pmc/articles/P…

2/

Lower back pain is the most prevalent & often challenging MSK condition out there

Here are some key texts in a 🧵 to help understand it better!

Let's start with this overview!

"What low back pain is and why we need to pay attention"

1/

pubmed.ncbi.nlm.nih.gov/29573870/ What types of back pain are there 🤷‍♂️

How prevalent are they 🤷‍♂️

How to identify them 🤷‍♂️

"Diagnostic triage for low back pain: a practical approach for primary care"

pubmed.ncbi.nlm.nih.gov/28359011/

2/

Back pain is a big problem. Especially when in the very painful acute stages.

‘Movement snacks’ can really help to keep the body moving, reduce stiffness & hopefully reduce pain!

Here are 5 to try!

1️⃣Knee pivots

Keep intensity low & ROM within comfortable limits! 2️⃣Rotations

Rotations can often be well tolerated IME, & also an under-utilised plane of movement

Use arms to limit ROM if this aggravates.

Non specific lower back pain (NSLBP) is the most common MSK problem world-wide.

It is also an often-misunderstood problem!

This 🧵 will help to de mystify what NSLBP is & is not & hopefully provide positive information to pass on to those suffering with NSLBP

1/15 What is it?

“pathoanatomical cause of the pain cannot be determined” - Maher

“For nearly all people presenting with low back pain, the SPECIFIC nociceptive source cannot be identified” -
- Foster

pubmed.ncbi.nlm.nih.gov/27745712/

Pain & it’s theories have been debated since the Greeks & Romans

Here is a short 🧵 on some pain theories that have shaped our modern perspectives on pain

Let’s start with the Descartes & the cartesian perspective of pain back in the 1600’s

1/

cambridge.org/core/books/abs… Melzack & Wall & the gate control theory started to challenge the 'specificity theory' of a simple linear transmission of a 'pain signal'

2/

pcpr.pitt.edu/wp-content/upl…

The challenge of exercise/movement prescription for pain is simplifying it away from an over complicated mechanical view, whilst still respecting the inherent complexity that exists across the biopsychosocial spectrum

My attempt to do this is the 3Ps model

1/ All models are of course wrong, but some are useful said Mr Box!

There are likely to be many potential mediators of recovery & this also depends on how recovery is defined.

Should this thinking be incorporated into clinical reasoning, hell yeah!

2/

Rehab often focuses on what is the best exercises, how to do those exercises & adjusting the variables associated with an exercise or activity

But can we improve ANY exercise/activity without changing anything physical? Absolutely, here is a 🧵 on how that can be done...

1/ What is said & done AROUND an exercise can have impact. This paper is a great example of how exercise being framed influences changes in pain

Negative pre exercise information changed the analgesic response of a wall squat in this paper

pubmed.ncbi.nlm.nih.gov/32366799/

2/

Here is a thread on our new paper 🧵

The biopsychosocial model is lost in translation: from misrepresentation to an enactive modernization

(this model didn't maker the final cut but represents putting it all together)

tandfonline.com/doi/abs/10.108…

1/

@Peter_Stilwell @sconinxphil Firstly, why did we write it?

Well there are many many interpretations of what Engel said that we wanted to go back and see what HE actually said & some of the history around the BPS & if the interpretations differ from Engels writing

2/