For the past several months I have been treating a patient we will call Tom. Tommy has 2 young kids, works too much in a stressful job, and has had a persistently painful back for the past 18 months.
It started as a tweak felt when leaning over the cot, and at first it was just an annoyance. But it didn’t go away. He tried a physio once or twice, who told him it was just his low back muscles going into spasm but got too busy to follow up.
Two months later he got fed up again and went to the chiropractor. Now the pain was burning and more constant. It had grown from an annoyance to a serious pain. “I will put my hands in a health professional and get it sorted once and for all”, he thought.
The chiropractor told him it was most likely because his pelvis was ‘out’. It was rotated and his leg was shorter on one side than the other. He showed him an X-ray like the one below and informed him that if he stuck to his treatments and the program, he could be ‘fixed.’
— Times Sport (@TimesSport) June 29, 2017
At first he thought it was helping. He attended diligently and definitely got some short-term relief after each session, but overall the pain hung around. It was at this point for the first (and not the last) time he started to panic. That little voice started to chirp ‘maybe the pain will never go away.’ ‘Maybe it will get worse.’ ‘Will I ever be able to run again?’ As Christmas rolled around, fortunately he had to go away so he stopped the treatments.
How to Cure Low Back Pain Naturally
Interestingly during the Christmas break, the pain was remarkably better. And why not right? He was swimming with the kids, basking in the hot sun, reading relaxing books. It wasn’t gone, but definitely felt better.
January rolled into February and he got a new manager at the office named John. John was confronting, and started challenging most of his work, making the environment pretty hostile.
At the same time, to add insult to injury, his back started to play up again. The burning began to creep down his leg, he still couldn’t run, and was now getting twinges whenever he sat in the car. A friend told him about an amazing osteopath who used some special techniques, and that he absolutely had to go see her.
The osteo was warm and very caring. She did a thorough exam and concluded that in fact, it wasn’t that the leg was shorter, but was rolling in too much. And those X-rays, well they can be biased she said. She felt the pelvis wasn’t the issue, but the muscles attaching the rib cage to the spine weren’t functioning properly. She pulled up diagrams up on the computer and educated him on how the muscles ‘work’ and where they can pull and lead to low back pain. The exam was very thorough and he left that day with renewed confidence.
Over the weeks she used special needles and movement techniques to help correct the pain. Immediately he felt better. Sure, the pain was coming back, but less so now. Yes, he thought, I am cured!! This person has fixed me. No one else found what she found.
But by the 4th week, the results weren’t quite the same. However, he now deeply trusted her and was willing to follow the program and stick it out. He gave it 6 full months. He had needling, muscle energy techniques, manipulations, specialized stretching, home exercises, but alas the pain still clung to him.
Pain and Depression
By now he was thoroughly depressed and anxious. He dropped osteo and went to a Chinese massage. He tried acupuncture. He got on a traction machine. He tried what he felt like was everything, but nothing worked. He felt frail. He felt like his body couldn’t move, and that his spine could snap at any time. He felt useless, was putting on weight, and he felt very alone. No one could understand just how bad his pain was and how much it that small little tweak had ruined his life. This is when he came to see me.
His neighbor had seen me and told him I was excellent at doing some of those techniques. He said he ‘absolutely had’ to come and see me. I still remember that first session, where with a mix of hope and skepticism he told me his story.
It is right here that I need to confess something that is the reason for writing this entire blog. If this was 5 years ago, I would have gone through the EXACT same process as the other practitioners mentioned. They were completely justified in doing what they did, and I would have and still do many of the same things.
But science has taught us a lot recently about the body and about how pain works, and I feel like it is necessary to start to unpeel many of the issues we see in current front line health care.
You see, what many health practitioners are coming to realize is that WE (and I have to shoulder as much blame as anyone) have just as much an impact on someone’s progress as the actual injury itself.
To understand this, you need to understand a few things.
The first lesson to learn is when an injury becomes persistent (that is lasting for longer than 12 weeks) it is not that relevant when it comes to how much pain you are experiencing. I know this is a polarizing statement but keep reading.
Pain is a production of our nervous system. When you go under an anesthetic, they put your brain to sleep, not your body. The brain takes many inputs such as how tired you are, how stressed and irritable your feeling, have you had a bad injury before, how you were brought up, your relationship etc AND the actual injury itself, to come up with an output of what we experience as pain.
And pain changes with experience. Universally people tell me their pain is worse at some times than others. It could be worse sitting, or standing, or walking, or only when they are at work, or driving, or doing the dishes, or with the kids, or whatever. Everybody’s experience is different.
And sometimes it’s better. Better when they are sitting, or standing, or walking, or only when they are at work, or driving, or doing the dishes, or with the kids – you get the drift.
Pain is as unique as a fingerprint. The inputs are variable and very complex, but one thing is for certain, and that is the actual injury only accounts for a small proportion of what you are feeling.
A study of using MRIs showing disc bulges showed no correlation between having a disc bulge and having pain. 70% of people had bulges. Some bulges hurt, others didn’t. Why is this?
But 99% of patients and therapists spend all of their time, money and energy into that part. The injury. The tissues. We must start to think differently with persistent pain.
It is not the tissues that determine pain, but rather your nervous system that interacts with the tissues, coupled with your experiences, that gives your perception of pain.
And don’t get me wrong. I believe in biomechanics as much as the next therapist. I believe in trying to correct things to improve performance and get the body working, but perhaps this article can help you understand just how off we therapists sometimes really are.
Therapists rarely ever agree on what they were seeing or feeling. And this isn’t between professions, this is within the same profession! But interestingly they also showed that between professions, we all get pretty similar results.
Soooo, if we are all treating different things, in different ways, but getting the same results, then what might really be happening?
Pain and Anxiety
Maybe it isn’t just the biomechanics, or special adjustment, or muscle technique, or exercise, or amazing practitioner you ‘absolutely’ have to see. Maybe it is something else…
This study was used to predict peoples pain and outcomes. To summarize, it found the more frightened and pessimistic you were, the less likely you were to recover. It was extremely accurate and sensitive, unlike many of the mechanical tests we use.
You can read here just how researchers found that the more (frightening) scans you had (telling you what’s wrong with you), the longer your treatment and recovery would be. Read: the more bad news you hear, the worse you’ll be.
And this is where we, as practitioners need to understand the research and simply be better. We can all agree to disagree whether a short leg matters, but what we say to you, as the patient, matters a lot. If I tell you early on that things look bleak, your spine is crooked, and there is a burst disc, I guarantee a long recovery time. We call it the NOCEBO effect, or opposite to placebo. Basically, if I tell you you’re stuffed, your brain will make sure you are.
However, if I tell you that yes we did find some problems, but your spine is strong and robust, and in 95% of cases it fully recovers quickly, you are more likely to have a shortened recovery time.
How many practitioners would want to straighten his spine??
No way can you run fast with a back that crooked? Obviously, you can. But Usain has had well-documented issues and pain with his back. He had troubles as a youngster and frequent hamstring strains.
But instead of just giving up or creating fear and doubt in his mind, his trainers did something amazing. They said ok, right now your back can’t tolerate what you are doing. Let’s build it up so it can. And they set about doing strengthening, and gym, and Pilates, and yoga and all sorts of things to help build up how much strain it could withstand. And he got his pain and problems under control. You can too.
What they realized was that pain isn’t the end result of a system that is broken, but merely a warning light that the system needs to calm down and build tolerance, and he went on to run the fastest 100m of all time.
Getting back to Tom. Instead of me giving him another reason to doubt the robustness of his spine, we took another approach. I got to work on helping him understand that bending over the cot that day was an activity he wasn’t used to, and something his tissues hadn’t built up for. So they became overloaded and he felt pain.
Over time his pain centers became more and more fired up due to stress, fear, load, fatigue and more.
Because everything was over sensitized, what could we do to dampen the system?
Here is what we did.
It’s now been 3 months. Tom is not ‘cured’ in the traditional sense of the word, but he has little to no pain. He can run 4km and ride a bike for 20 minutes. He plays with the kids and feels like he has got his life back. If he goes over these loads, he does experience sensitivity. But now he understands, he just needs to keep building his tolerance and resilience.
He sent me a note saying thank you for everything. I tore it up. This isn’t me being faux humble – I’ll take as much praise as you want to give me. But this is me saying once and for all to patients – your therapist is not your guru. They can help you, but they can’t fix you, only you can do that. Find one that empowers you to build your confidence and strengthen your body.
Knowledge is power, and he is back in the driver’s seat of controlling his future.
Chris Jellis is a clinical physiotherapist, has worked in private practice for the past 10 years, and is one of the directors of the Sum Of Us studio. Sum of Us is a health and wellness studio in Prahran that combines the science of modern physiotherapy and health care, with the beauty and aesthetics of a luxurious, nourishing environment. For more information go to www.sumofusstudio.com.au