Darcy Coss interviewed me for his really cool podcast "Back2Basketball". Having an amazing rehabilitation journey by himself we had a nice talk about:

• the biggest thing people get wrong about their backpain (11:55)
• the importance of movement (24:36)
• the importance of posture (28:10)
• how to change your sitting behaviour (30:27)
• mindfulness (42:21)
• first steps to start your rehabilitation and feeling better (48:26)

Please check out Back2Basketball:

Instagram: @back2basketball

Podcast: https://linktr.ee/back2basketball

- What you should know about MRI and Xray when you have low back pain -

Most of typical imaging (making an mri, ct or xray) findings of people with LBP are part of normal aging and are not related to back pain. Using these images to explain your pain without an accurate examination and a carefully guided clinical history interview, is not supported by current scientific evidence!

Clinical guidelines say imaging should be avoided unless signs that raise suspicion for a serious underlying condition like malignancy, spinal fracture, infection of the spine, or cauda equina syndrome are present.1,2,3,4

These signs are usually called 'red flags'. And only a very small percentage of LBP categorises for this group of severe pathology, usually around 1% -> Most people do not show such signs.

Are you having serious disease? (red flags)

A potential serious disease is identified by your medical doctor while taking a focused history and looking/listening for so called "red flags". "Red flags are features from the patient's clinical history and physical examination which are thought to be associated with a higher risk of serious pathology."5 There is no definite list of red flags, but the most commonly used are2:

• aged over 50 years old
• history of cancer
• steroid use

Other commonly suggested "red flags" in clinical practice guidelines are5,2:

• faecal incontinence
• urinary retention
• widespread neurologic symptoms (could be a palsy, marked weakness of muscles, decreased sensation (feeling numb on your skin), something seriously wrong with your reflexes and your medical doctor will know how to look for that)
• no improvement in symptoms after one month
• unexplained weight loss
• fever
• being systematically unwell

Whilst the use of red flags is recommended by all clinical guidelines there is still little empirical data for its diagnostic accuracy.5,6 If a combination of red flags raises the suspicion of your clinician he or she should assess prognostic factors such as X-rays and blood tests or magnetic resonance imaging to rule out or identify serious disease (malignancy, spinal fracture, infection of the spine, cauda equina syndrome). The so often mentioned slipped disc by itself is not considered a severe pathology!

So why is imaging of your spine not recomended in the absence of red flags?

To put it simple: People with no LBP can have worse mri´s, ct`s or xray´s than people with LBP.

Most of typical imaging findings of people with LBP (such as disk degeneration, disk signal loss, disk height loss, disk protrusion, and facet arthropathy) are part of normal aging and are also present in 90% of individuals 60 years of age or older without even having LBP. Also more than 50% of people without any LBP between 30-39 years of age have disk degeneration, height loss, or bulging in their imaging findings.7

Furthermore no association was identified between findings like spondylolysis, isthmic spondylolisthesis, or degenerative spondylolisthesis, and the the occurrence of LBP.8 No association between lumbar spine facet joint osteoarthritis, identified by multi-detector CT, at any spinal level and LBP.9

Findings on mri are also not predictive of the development or duration of low-back pain.10 Individuals with the longest duration of LBP did not have the greatest degree of anatomical abnormality.11

A recent systematic review concluded that in the acute setting of sciatica (pain radiating down the leg), evidence for the diagnostic accuracy of MRI is not conclusive.12

Let´s put in an example:

If you randomly choose 100 people above 30 years of age that do not have LBP and feel perfectly fine, more than 50 of them will show the typical signs of degeneration that are often (mis)used to explain the cause of LBP.

The same stands true for people with LBP. They too have a good chance to show those signs, but it is just a normal picture, your skin too does not look like the skin of a 10 year old. It´s in most cases a normal part of aging and has no corelation with pain.

So getting an xray, ct or mri not only will not help you (if you lack signs of serious pathology) in treating your back pain but there are even studies that suggest that having an MRI can make things worse for people with LBP. In a study done with 3264 workers compensation cases, people with MRI came off of disability 200% slower than those who didn´t have an MRI scan.13

What really should make one think is that 80-100% of the MRI group had surgery while

the no-MRI group had a surgery rate of less than 10%, still having a much faster recovery. Another study brings further evidence for worse outcomes of people with LBP that have early MRI´s regardless of radiculopathy (back and/or leg pain with muscle weakness. On average, the rate of going off disability for those who received an early MRI was approximately one-third the rate of those who did not receive MRI. "hThis evidence reinforces that both providers and patients should be made aware that when early MRI is not indicated, its use provides no benefits and could result in worse out- comes such as iatrogenic work disability and unnecessary medical procedures."14

Iatrogenic work disability means, work disability caused by health professionals.

As researcher Neil o´Connell points out in an article he wrote for www.bodyinmind.org: "(...) it's not really the scans that are the problem, it's the way that they are (mis)used by clinicians. Powerful images of bulging discs, degenerating joints, partial dislocations or instability are evoked to help explain the patient's symptoms (...)"

Using these images to explain your pain without an accurate examination and a carefully guided clinical history interview, is not supported by current scientific evidence! Instead of helping you in your recovery, it could create fear, fear of movement, and probably will even contribute to your pain-condition because of that.

Remember: If you already have a mri, ct or xray of your back and worry about those "abnormalities" described by the radiologist, many people without LBP would have similiar results in their mri´s or xrays. It´s perfectly normal for a spine to show osteoarthritis, disc narrowing, spondylolisthesis discs bulging aso. It´s like having wrinkels on our skin as we are getting older.

For LBP with substantial neurologic involvement, CPGs generally did not recommend conducting any further assessment until appropriate conservative management (which was rarely defined) had failed, after which MRI or CT was generally recommended.2 Imaging is sometimes recommended where sufficient progress is not being made but the time cut-off varies from 4 to 7 weeks.1

Find out more: www.mybackrecovery.com

Literatur:

1. Koes BW, van Tulder M, Lin C-WC, Macedo LG, McAuley J, Maher C. An updated overview of clinical guidelines for the management of non-specific low back pain in primary care. Eur Spine J. 2010;19(12):2075-2094. doi:10.1007/s00586-010-1502-y.
2. Dagenais S, Tricco AC, Haldeman S. Synthesis of recommendations for the assessment and management of low back pain from recent clinical practice guidelines. Spine J. 2010;10(6):514-529. doi:10.1016/j.spinee.2010.03.032.
3. Pillastrini P, Gardenghi I, Bonetti F, et al. An updated overview of clinical guidelines for chronic low back pain management in primary care. Jt Bone Spine. 2012;79(2):176-185. doi:10.1016/j.jbspin.2011.03.019.
4. B.K. C, J.L. B. Appropriate and safe use of diagnostic imaging. Am Fam Physician. 2013;87:494-501. http://www.aafp.org/afp/2013/0401/p494.pdf\nhttp://ovidsp.ovid.com/ovidweb.cgi?T=JS&PAGE=reference&D=emed11&NEWS=N&AN=2013206181.
5. Henschke N, Cg M, Rwjg O, et al. Red flags to screen for malignancy in patients with low-back pain ( Review ). Program. 2013;(2). doi:10.1002/14651858.CD008686.pub2.Copyright.
6. Downie A, Williams CM, Henschke N, et al. Red flags to screen for malignancy and fracture in patients with low back pain: systematic review. Bmj. 2013;347(dec11 1):f7095-f7095. doi:10.1136/bmj.f7095.
7. Brinjikji W, Luetmer PH, Comstock B, et al. Systematic literature review of imaging features of spinal degeneration in asymptomatic populations. AJNR Am J Neuroradiol. 2015;36(4):811-816. doi:10.3174/ajnr.A4173.
8. 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 (Phila Pa 1976). 2009;34(2):199-205. doi:10.1097/BRS.0b013e31818edcfd.
9. Kalichman L, Li L, Kim DH, et al. Facet joint osteoarthritis and low back pain in the community-based population. Spine (Phila Pa 1976). 2008;33(23):2560-2565. doi:10.1097/BRS.0b013e318184ef95.
10. Borenstein DG, O'Mara JW, Boden SD, et al. The value of magnetic resonance imaging of the lumbar spine to predict low-back pain in asymptomatic subjects : a seven-year follow-up study. J Bone Joint Surg Am. 2001;83-A(9):1306-1311. http://www.ncbi.nlm.nih.gov/pubmed/11568190.
11. el Barzouhi A, Vleggeert-Lankamp CL a M, Lycklama à Nijeholt GJ, et al. Magnetic resonance imaging in follow-up assessment of sciatica. N Engl J Med. 2013;368(11):999-1007. doi:10.1056/NEJMoa1209250.
12. Wassenaar M, van Rijn RM, van Tulder MW, et al. Magnetic resonance imaging for diagnosing lumbar spinal pathology in adult patients with low back pain or sciatica: a diagnostic systematic review. Eur Spine J. 2012;21(2):220-227. doi:10.1007/s00586-011-2019-8.
13. Webster BS, Cifuentes M. Relationship of early magnetic resonance imaging for work-related acute low back pain with disability and medical utilization outcomes. J Occup Environ Med. 2010;52(9):900-907. doi:10.1097/JOM.0b013e3181ef7e53.
14. Webster BS, Bauer AZ, Choi Y, Cifuentes M, Pransky GS. Iatrogenic consequences of early magnetic resonance imaging in acute, work-related, disabling low back pain. Spine (Phila Pa 1976). 2013;38(22):1939-1946. doi:10.1097/BRS.0b013e3182a42eb6.

Through relaxation you can break the vicious circle of pain and stress. This podcast takes you through some easy to learn methods of relaxation, helping it to become part of your daily life and improving your wellbeing. It also lists the benefits of meditation and looks at the supporting scientific evidence, examining why relaxation should be an integral component in your recovery.

Relaxation

Relaxation is an integral component of cognitive behavioral treatment programs for chronic pain.1 Taking care of stress and anxiety as a chronic pain patient is crucial for your recovery.

Meditation

Meditation is also a great way to built relaxation into your daily life. There are many different ways of practicing meditation and you have to find what works best for you.

Many people enrich their lives through practicing meditation.

When you read interviews with successful CEO´s, entrepreneurs or celebrities who have incorporated meditation routines in their lives it is astonishing to see the huge benefits they experience.

Personal benefits of people who meditate regularly:

more happiness

having more energy

having more creativity

living more efficiently

a better understanding of ones own emotions

more sensitivity to the feelings and emotions of others

more control over ones own emotions

less pressured by your experiences

less stressed

feeling more relaxed

more calming thoughts

control over your sensory filtering

improved memory and executive function

increased ability to concentrate

increased emotional intelligence

Thinking about relaxation, mindfulness and awareness during our recovery can't be done without looking at some important evidence and thoughts about meditational practices:

Mindfulness meditation programs improve anxiety, depression and pain over the course of 2–6 months. The effects are comparable with those you can expect after taking antidepressants for the same period of time, but without the associated toxicities.2

47 placebo-controlled trials all found small to moderate improvements in pain, anxiety and depression. What is really great about this review (Meditation programs for psychological stress and well-being from 2013) is that it demonstrates that the meditation group attained better results compared to the control group undertaking an equally intense treatment regarding focus and time, such as lectures, talks and art therapy sessions.

If we consider this evidence, then it seems a good reason to check out mindfulness for yourself and see if meditation could be something for you to try.

A definition of mindfulness

Mindfulness has been described as a "non-elaborative, non-judgmental awareness" of present moment experience.3

Maybe you have heard of Zen, it´s very closely related to the mindfulness approach.

In general mindfulness techniques can be divided into two styles:

focused attention

"Focused attention is associated with maintaining focus on a specific object, often the changing sensation or flow of the breath or an external object. When attention drifts from the object of focus to a distracting sensory, cognitive or emotional event, the practitioner is taught to acknowledge the event and to disengage from it by gently returning the attention back to the object of meditation".3

open monitoring

"By contrast, open monitoring is associated with a non-directed acknowledgement of any sensory, emotional or cognitive event that arises in the mind. Zen meditation is considered to be one form of open monitoring practice. While practicing open monitoring, the practitioner experiences the current sensory or cognitive 'event' without evaluation, interpretation, or preference".3

Many guided meditation programs consist of a mix of those two styles. Often changing from one to the other within a meditation session.

I also think that it's really important to know that clinical research into mindfulness has been going on since the early 1980s. For me this means that there is a good scientific evidence for using meditation techniques detached from religious beliefs or dogma for health purposes.

How to start

There is plenty of good content on the Internet available for free, simply search for mindful meditation. Check out some talks about meditation on TED.com and be inspired, or check out www.mindful.org

Here are some great resources: Free guided meditations from UCLA:

Each week has a different theme, and usually includes some introductory comments, a guided meditation, some silent practice time, and closing comments. Presented by the UCLA Mindful Awareness Research Center.

http://marc.ucla.edu/body.cfm?id=107

http://marc.ucla.edu/body.cfm?id=22

UCSD Center for Mindfulness:

Guided audio files for practicing Mindfulness-Based Stress Reduction (MBSR) from the UC San Diego Center for Mindfulness.

http://health.ucsd.edu/specialties/mindfulness/programs/mbsr/Pages/audio.aspx

Basic meditation with Tara Brach Free meditations that you can stream or download.

https://www.tarabrach.com/guided-meditations/

Contemplative Mind in Society Guided practices from Mirabai Bush, the center's director, Diana Winston from UCLA's Mindfulness Awareness Research Center, and Arthur Zajonc, president of the Mind & Life Institute.

http://www.contemplativemind.org/practices/recordings

Insight Meditation Society Selected talks, podcasts, and audio streams, including various lengths of guided meditation.

http://www.dharma.org/resources/audio#guided

John Kabat Zinn on youtube:

Professor of Medicine Emeritus and creator of the Stress Reduction Clinic and the Center for Mindfulness in Medicine, Health Care, and Society at the University of Massachusetts Medical School.

https://www.youtube.com/watch?v=8HYLyuJZKno

Literature:

1. Morley S, Williams A. New Developments in the Psychological Management of Chronic Pain. CanJPsychiatry. 2015;6060(44):168-175.
2. Goyal M, Singh S, Sibinga E, et al. Meditation programs for psychological stress and well-being : a systematic review and meta-analysis. JAMA Intern Med. 2014;174(3):357-368. doi:10.1001/jamainternmed.2013.13018.Meditation.
3. Zeidan F, Grant J., Brown CA, et al. Mindfulness meditation-related pain relief: Evidence for unique brain mechanisms in the regulation of pain. Neurosci Lett. 2012;520(2):165-173. doi:10.1016/j.neulet.2012.03.082.

Goal-setting can support your recovery from back pain and lead you to a better quality of life. Part 2 of this episode shows you proven techniques that help you in achieving what you aim for. + download your personal goal-setting sheet for free!!!

Get your free Personal-Goal-Setting-Sheet here

Part 1 was about what you should aim for in your recovery:

1. Increasing physical activity1,2,3,4
2. improving sleep quality4,5
3. managing stress4,6

Now let´s dig in how goal-setting can help us in achieving that.

In their Article from 2002 Edwin Locke from University of Maryland and Gary Latham from Univerity of Toronto sum up the evidence about what science knows about the mechanisms of goal-setting.7

Goals affect performance through four mechanisms:

• direct attention and effort
• energizing function
• goals affect persistence, hard goals prolong effort (important for us, recovery process is a long term comittment)
• goals affect action indirectly by leading to the arousal, discovery, and/or use of task-relevant knowledge and strategies

To sum it up: "Effects of Goal-Setting are very reliable. Goal-setting theory is among the most valid and practical theories in organizational psychology."7

Those with high specific goals reach higher performance than those who tried to do their best. It´s not always that easy and we will talk about what research tells us, what is important in defining goals that help reaching higher performance. And thats exactly what we are looking for.

They further conclude:7

a goal should be specific,

proximal goals should be added,

proper use of learning goals should be made.

What does this mean?

A general goal would be: Increasing physical activity.

A specific goal would be: Increase walking distance up to 20 min a day. Translated into a proximal goal: Walk 20 min every day for one week starting today.

And you could also add a strategy: Walk 20 min every day, before a get into the car driving to work starting today, or getting out of the bus-stop one station before my destinantion and walk there. Be creative!

So thinking about activity:

Set specific Goals.

Add a proximal goal and add a strategy

Be clear about why you are doing this!

You are not doing this right now to become instantly pain free, you want to increase physical activity, increase quality of sleep and manage stress because in the long run that is what you will benefit from and as aresult will increase your quality of life.

Start with something that you are confident to achieve.8

No doubt there should be some challenge within your set goals. Sucess in reaching your goals will feed your confidence and step by step you can start set higher goals for your self. Goal setting is also about self efficacy, which means confidence in that you can achieve your goals. So thats a reward on it´s own, and we need that in roder to go on with our recovery.

Goals lead to higher performance when people are committed to their goals and receive summary feedback.

And there are several ways you can enhance commitment.

Through factors that make goal attainment important for you

First of all write your goal down. Put your Goals somewhere where you can see them, so that you stay focused and you reflect upon them.

Having an accountability buddy helps in multiple ways. The announcement to another person will raise the importance of xour goals for you and if you hold a weekly conversation where you report about your progress or difficulties you will have a fixed time to reflect upon your situation and this feedback will enable you to find better strategies to overcome difficulties.

Resource Section: Goal-Setting-Sheet

Get your free Personal-Goal-Setting-Sheet here

Set your goals for each day and at the end of the day reflect on them. Did you made it? Great! If not reflect about the reasons for it. Can you think of any strategy how to achieve your goal the next time you will be in the same situation? Could you ask someone for help if it is a time problem? Any strategy is better than no strategy. And by trying out new things you probably will come along with better and better strategies that will work for you.

If you are short on time, make it a 5 min goal. Maybe some stretching, or mobilisation-technique that you already know that you can do before you go to sleep.

Find more information at www.mybackrecovery.com

Literature:

1. Sackett DL, Rosenberg WMC, Gray JAM, et al. Evidence based medicine: what it is and what it isn't. 1996. Clin Orthop Relat Res. 2007;455:3-5. http://www.ncbi.nlm.nih.gov/pubmed/17340682. Accessed December 16, 2012.
2. Manske RC, Lehecka BJ. Evidence - based medicine/practice in sports physical therapy. Int J Sports Phys Ther. 2012;7(5):461-473. http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=3474298&tool=pmcentrez&rendertype=abstract. Accessed December 16, 2012.
3. Jette DU, Bacon K, Batty C, et al. Evidence-based practice: beliefs, attitudes, knowledge, and behaviors of physical therapists. Phys Ther. 2003;83(9):786-805. http://www.ncbi.nlm.nih.gov/pubmed/12940766. Accessed October 5, 2012.
4. Hooten W, Timming R, Belgrade M, et al. Assessment and Management of Chronic Pain.; 2013.
5. Pakpour AH, Yaghoubidoust M, Campbell P. Persistent and developing sleep problems: a prospective cohort study on the relationship to poor outcome in patients attending a pain clinic with chronic low back pain. Pain Pract. 2017:1-2. doi:10.1111/papr.12584.
6. Morley S, Williams A. New Developments in the Psychological Management of Chronic Pain. CanJPsychiatry. 2015;6060(44):168-175.
7. Locke E a, Latham GP. Building a practically useful theory of goal setting and task motivation: A 35-year odyssey. Am Psychol. 2002;57(9):705-717. doi:10.1037/0003-066X.57.9.705.
8. Bodenheimer T, Handley MA. Goal-setting for behavior change in primary care: An exploration and status report. Patient Educ Couns. 2009;76(2):174-180. doi:10.1016/j.pec.2009.06.001.

8.1 Setting Goals to Boost Your Recovery from Back Pain - Part 1

What we should aim for in our recovery process and how setting the right goals can help us with that.

What to aim for

The most effective treatments for low back pain include exercise or multidisciplinary rehabilitation (also see Episode 06).

Passive treatments, on the other hand, have not been demonstrated to induce long-term improvements.1

1. Physical Activity and Therapeutic Exercise 2,3,4,5

This is what we know what will help in the long term. Increasing activity. Developing a set of active coping strategies.

1. Improve Sleep5

Improving sleep also makes total sense, since over 50% of people living with chronic pain suffer from depression and there is a strong correlation between quality of sleep and depression. And depression has an impact on your recovery process.5

"Presenting, persistent, and developing sleep problems have a significant impact on recovery for those with LBP"6

According to the "2015 sleep in america poll", making sleep a priority is linked to better sleep, even among those with pain. Setting the right goals has a direct impact on your life.7

Check out the videos of the national sleep foundation about sleep and chronic pain:

Sleep and Pain: Beat the Cycle and Improve Your Sleep Today

https://sleep.org/articles/sleep-pain-beat-cycle-improve-sleep/

Chronic Pain and Sleep

https://sleepfoundation.org/sleep-disorders-problems/pain-and-sleep

What is Sleep Hygiene

https://sleep.org/articles/sleep-hygiene/

1. Manage Stress5

Relaxation is an integral component of cognitive behavioral treatment programs for chronic pain.8

-formal interventions are for example: therapy, counceling classes, support group,

relaxation techniques, meditation, yoga, breathing exercices, autogenic trainingcreative activity....-

There is a lot of research how people living with chronic pain can benefit from meditation and relaxation techniques. Watch out for the next episode!

Part 1 of this episode examined what you should be aiming for in your recovery and why this is important.

Part-2 will show you proven techniques that help you in achieving what you aim for.

find out more on www.mybackrecovery.com

Literature:

1. Scheermesser M, Bachmann S, Schämann A, et al. A qualitative study on the role of cultural background in patients' perspectives on rehabilitation. BMC Musculoskelet Disord. 2012;13(5):5. doi:10.1186/1471-2474-13-5.
2. Sackett DL, Rosenberg WMC, Gray JAM, et al. Evidence based medicine: what it is and what it isn't. 1996. Clin Orthop Relat Res. 2007;455:3-5. http://www.ncbi.nlm.nih.gov/pubmed/17340682. Accessed December 16, 2012.
3. Manske RC, Lehecka BJ. Evidence - based medicine/practice in sports physical therapy. Int J Sports Phys Ther. 2012;7(5):461-473. http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=3474298&tool=pmcentrez&rendertype=abstract. Accessed December 16, 2012.
4. Jette DU, Bacon K, Batty C, et al. Evidence-based practice: beliefs, attitudes, knowledge, and behaviors of physical therapists. Phys Ther. 2003;83(9):786-805. http://www.ncbi.nlm.nih.gov/pubmed/12940766. Accessed October 5, 2012.
5. Hooten W, Timming R, Belgrade M, et al. Assessment and Management of Chronic Pain.; 2013.
6. Pakpour AH, Yaghoubidoust M, Campbell P. Persistent and developing sleep problems: a prospective cohort study on the relationship to poor outcome in patients attending a pain clinic with chronic low back pain. Pain Pract. 2017:1-2. doi:10.1111/papr.12584.
7. 2015 Sleep in America Poll. Sleep Heal. 2015;1(2):e14-e375. doi:10.1016/j.sleh.2015.02.005.
8. Morley S, Williams A. New Developments in the Psychological Management of Chronic Pain. CanJPsychiatry. 2015;6060(44):168-175.

Training and activity is your no1 option when recovering from low back pain.

This episode introduces two of the most important exercises for building up strength within your lower back and practice movement control.

Strength Training for People with Low Back Pain

Always check with your medical professional if it is save for you to exercise! This exercises are not a substitute for individual medical treatment but aim to complement and support your recovery process.

Find all videos for this episode on:

http://mybackrecovery.com/resources.page

video episode 07

The exercises we are going to explore on this episode build up on your basic movement control skills and are both:

• challenging your movement control skills
• helping you building up strength and strength endurance within your back muscles

If you have listened to episode 06 you already have come to learn that clinical guidelines recomend therapeutic exercise and activity with strong supporting evidence for the management of chronic low back pain.

A recent review concluded that: "The hypothesis of specific lumbar extensor deconditioning as being a causal factor in LBP is presently well supported." meaning: weak back muscles could cause LBP.1

It further says: "It is by no means the only causative factor and further research should more rigorously test this hypothesis (...) however specific exercise may be a worthwhile preventative and rehabilitative approach."

In this episode i will share some of my most favorite exercises for building up strength within your back extensor muscles and practice movement control. These classis exercises will give you more options with your training, and will take your training to the next level.

Training introduced on 'my Back recovery' so far:

Episode 03:

Easy and back specific circle training with save loading profiles in terms of exercising. A first step in starting to work on strength and strength endurance as well as stability. Also a great way of improving blood flow in your muscles.

video

Episode 05:

Movement control exercises - basic skills for exercising - moving your pelvis/hip influences the posture of your lower back - being able of keeping a neutral position during certain exercises.

video

As you learned the basics for movement control (ep 5) and started to get familiar with a back specific circle training (ep 3) it´s time for you to take the next step!

'Good Morning' & Squat

Video

The good morning and the squat are static exercises for your back. This means no movement in the back while you are doing the exercises. They are more difficult to perform than the exercise-set from episode 03.

It really pays of focusing on doing the good morning and the squat with correct posture! Once you got this you can do most of other exercises in a correct way and will have more options to adjust exercises to your own needs. Remember to always adjust your exercises to your individual situation so that you are able to perform pain free and without aggravation of your symptoms.

Good Morning

The 'good morning' is great for building strength2 and movement control. Actually the 'good morning' is also used as a part of a validated test series used to detect impaired movement control within people with LBP.3

It works the gluteus, hamstrings and lower back.

Basically the 'good morning' is about bending forward with a straight (neutral) back.

Remember the last movement control exercise from episode 05: sitting and rocking forward and backward while keeping a moderate arch of your lower back with no movement in the back. The good morning exercise is the same in a standing position.

Stay upright, bend your knees slightly. This will help you doing the movement from your hips (because your hamstrings are not that much stretched when you are bending your knees).

Bend forward while you are keeping a straight back (remember straight means slightly curved, we wanna see a moderate arch (like a weightlifter) at the lower back, if your back seems to be flat, it is already flexed, we want to trigger those back extensor muscles and keep a neutral position thats why we need that arch!

This exercise should be pain free! So if you are doing it correctly and start to experience pain while leaning forward, remember the golden training principles. Adjust the exercise. Don´t go so far. Maybe you can do it leaning fwd 45 degrees out from the vertical position and will feel fine, and pain starts only if you go further. So respect your pain and adjust the exercise.

Most people who hadn´t done this kind of exercise will find it difficult to perform in the beginning.

Here is how i teach the 'good morning' to my clients:

First i start with all the exercises from episode 05. If you havent mastered these go back and work on them until you feel comfortable with them.

video - basic movement control skills episode 05

Most of the time the problem is that people don´t know how to keep good posture in their lower back. The movement you need to do is 'push your bum out while leaning forward'. This will result in hip flexion and back extension and result in a moderate arch in your lower back. Again some people could experience discomfort when arching to much. So experiment and find a position that is comfortable and pain free. The basic movement control skills from episode 05 will help you with that!

Than i let my clients sit on a high chair or at the edge of a table with their feet standing on the ground. Now it´s like a mix of the rocking forward and backward exercise we did at the end of episode 05, and the good morning. It´s a bit easier than in the standing position. If you feel fine proceed to the standing position.

It´s natural that when leaning forward to much, you will loose the arch in your lower back. So just go as far as it is pain free and you can keep correct posture.

Even when you are doing only a small movement like 10-20 degrees forward bending you still train your muscles and start to practice movement control.

One thing i experience quite often when people are doing the good morning is that they are squatting simultaneously. Although there is nothing harmful with this i suggest making two exercises out of it and not mixing the good morning and the squat. With this strategy you will gain better movement control and have more variability in you training options. So keep your knees slightly bent but try not to squat while leaning forward, and check this in a mirror from your side! You have to actively work for not bending your knees while leaning forward.

Squats

Absolut classics! Squats also work your back extensor muscles. Squatting is a typical everyday activity. Besides working all major muscle groups in your body and helping you stay fit, good form/posture with squatting will help you becoming more aware of your posture in everyday activities. The squat is almost the same as the good morning but with knee-movement and less dynamic leaning forward and backward.

Starting position: Standing upright, having your weight evenly distributed to both of your feet, leaning a bit forward and squatting down. Again keep that lower back arched when leaning forward.

If you can control your back already let´s check your knees. When squatting down look to your knees and feet: have your toes pointing straight forward and try to keep your medial border of your kneecap outside of your big toe. This will result in proper hip knee ankle alignment and less stress and strain on your knee. 4, 5

You can do the squat in a narrow stance or a wide stance. But keep your feet pointing forward and mind your knee position!

find more information at www.mybackrecovery.com

Literatur:

1. Steele J, Bruce-Low S, Smith D. A reappraisal of the deconditioning hypothesis in low back pain: review of evidence from a triumvirate of research methods on specific lumbar extensor deconditioning. Curr Med Res Opin. 2014;30(January):1-47. doi:10.1185/03007995.2013.875465.
2. Steele J, Bruce-Low S, Smith D. A Review of the Clinical Value of Isolated Lumbar Extension Resistance Training for Chronic Low Back Pain. PM R. 2014;(OCTOBER 2014):1-18. doi:10.1016/j.pmrj.2014.10.009.
3. Luomajoki H, Kool J, de Bruin ED, Airaksinen O. Movement control tests of the low back; evaluation of the difference between patients with low back pain and healthy controls. BMC Musculoskelet Disord. 2008;9(Mc):170. doi:10.1186/1471-2474-9-170.
4. Lee TQ, Morris G, Csintalan RP. The influence of tibial and femoral rotation on patellofemoral contact area and pressure. J Orthop Sports Phys Ther. 2003;33(11):686-693. doi:10.2519/jospt.2003.33.11.686.
5. Koga H, Nakamae A, Shima Y, et al. Mechanisms for noncontact anterior cruciate ligament injuries: knee joint kinematics in 10 injury situations from female team handball and basketball. Am J Sports Med. 2010;38(11):2218-2225. doi:10.1177/0363546510373570.

The second part of episode six takes a tour into the scientific world of clinical research, exploring how clinical guidelines are created and looking at why they are important.

Clinical guidelines promote evidence-based practice by giving out recommendations according to available evidence from systematic research and can therefore have a great impact on your recovery plan.

How is a guideline formed?

Firstly a vast amount of scientific literature is systematically searched from within clinical databases and then checked for relevance.

The next step critically grades all the studies according to their methodological quality (a very good study has more impact than a study with potential for bias).

These steps are usually all undertaken parallel by at least two people and then the results are compared. These findings are then finally summarized and recommendations are drawn.

If you want to take a closer look into the world of research, I recommend you check out the Grade Handbook on the gdt.guidelinedevelopment.org webpage. This is a good in-depth explanation how guidelines are created. The handbook can also be found through the Internet by searching for "Handbook for grading the quality of evidence and the strength of recommendations using the GRADE approach".

Selecting the best information available when creating a guideline

Every single study that contributes to a guideline or systematic review, is a scientific piece of work with high standards (some higher or lower, hence the grading system).

Therefore scientists and researchers try hard to control every little detail within their studies and here are a couple of examples of how they do that:

If you want to find out if strength-training works for people with LBP you can't just ask people with LBP to sign up for a strength-training class because this could result in selection bias: Only people who believe in strength training would participate, and this group of people is not representative for the average LBP-patient.

The group has to be selected from real patients with LBP ideally randomly assigned to one of two groups, a strength-training group and a control group.

In order to control the study results for a placebo effect, both groups should undergo active intervention of equal activity time. For example the control group could undertake a stretching routine.

Wherever possible the patients should not know which group they are in (this is called blinding of patients). The therapists should also not be aware which group is which, this is because it could also have an effect on the treatment outcome! (Don't believe me? Check out the "rosenthal- or hawhorne- or helo-effect). This is however not always possible, but would be the ideal.

The 'blinding' should also include those recording and adjudicating the outcomes for both groups.

Furthermore the endpoint of the study should be defined in advance. The study must always continue up to the predefined end, neither lengthened nor shortened as this can lead to a distortion of the results.

As positive study results are more likely to be published, researchers searching of systematic reviews try to evaluate possible publication bias. For example, if a study is sponsored by a specific company or industry the results could be considered biased and the evidence is down graded.

Why is it important to read guidelines?

Researchers know about all the problems mentioned above, and they also try to tackle them in the best possible ways.

I think it is really important to be informed and know about the limitations of research and at the same time value its results, since it's the only real evidence, along with your own personal experience, and the personal experience of the medical professionals trying to be of service to you, that you have in helping you make an informed decision about which treatment to take.

All in all a lot of effort goes into the creation of a guideline!

Find out more: www.mybackrecovery.com

Recommendations based on current available evidence helps you combine your personal experience and expectations with research to form an individual treatment plan and find treatments with the most promising results.

What treatment should I consider for my back pain?

There are many guidelines regarding LBP and some even especially for chronic LBP.

In this episode you will find information about the treatment options often recommended in these guidelines.

Setting evidence into your personal situation

After having examined all the best available evidence from systematic research it is important to know how to apply this information to your individual situation.

Evidenced based treatment is more than simply the best available evidence from systematic research alone.

It should also take into account the expertise of your clinician(s) as well as your personal expectations, beliefs and preferences!1,2,3

Treatment Recommendations with strong supporting evidence

• Information, education and self-care

"All the guidelines explicitly underline the importance of educating and providing patients with information on LBP with regard to their expected course and the possibility of effective prevention and selfcare options."4

• Physical activity and therapeutic exercise

"There is strong evidence that physical activity and therapeutic exercise are effective for the management of CLBP, even if it is not clear what kind of exercise is best. An individual, graded and active exercise program supervised by an expert (physical therapist) is almost always recommended."4

• Multidisciplinary treatment programs

"Combined physical and psychological interventions with cognitive-behavioral therapy and exercise are particularly recommended for people who have received at least one course of less intensive treatment and have high disability and/or significant psychological distress."4

All other forms of treatment are currently categorized using the following descriptions:

Might do - recommendations with moderate supporting evidence

Don't know - recommendations with limited or inconclusive evidence

Don't do - recommendations with strong evidence against intervention

For more information of other treatment options please refer to the original article which can be found via the Internet: "An updated overview of clinical guidelines for chronic low back pain management in primary care."4

Find out more: www.mybackrecovery.com

Literature:

1. Sackett DL, Rosenberg WMC, Gray JAM, Haynes RB, Richardson WS. Evidence based medicine: what it is and what it isn't. 1996. Clin Orthop Relat Res. 2007;455:3–5. Available at: http://www.ncbi.nlm.nih.gov/pubmed/17340682. Accessed December 16, 2012.
2. Manske RC, Lehecka BJ. Evidence - based medicine/practice in sports physical therapy. Int J Sports Phys Ther. 2012;7(5):461–73. Available at: http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=3474298&tool=pmcentrez&rendertype=abstract. Accessed December 16, 2012.
3. Jette DU, Bacon K, Batty C, et al. Evidence-based practice: beliefs, attitudes, knowledge, and behaviors of physical therapists. Phys Ther. 2003;83(9):786–805. Available at: http://www.ncbi.nlm.nih.gov/pubmed/12940766. Accessed October 5, 2012.
4. Pillastrini P, Gardenghi I, Bonetti F, et al. An updated overview of clinical guidelines for chronic low back pain management in primary care. Jt Bone Spine. 2012;79(2):176–185. doi:10.1016/j.jbspin.2011.03.019.

Movement control not only helps you control your posture and position whilst exercising but can also help you adjust exercises to your own personal needs by controlling stress and strain on the spine.

This episodes guides you through impaired movement control, lists exercises to improve your ability to control movement and talks about the resulting benefits in your experience of pain and everyday activity.

Movement-Control – a Basis for Healthy Training

Therapists and trainers have always highlighted the value of good posture and position, and now science also backs up the importance of movement control for people recovering from chronic low back pain.

Traditionally movement control is taught by therapists and trainers in order to gain control over the position of your spine as a basis to:

• exercise in a healthy way
• adjust exercises to your own needs
• control stress and strain on your spine in your everyday activities

Your brain adapts according to your needs

There is scientific evidence to promote movement control as a therapy approach. Today it is widely accepted that chronic LBP is often not caused by a single structure at fault in the back. At least this is the case with 80-95 %, which is why this group is called non specific low back pain.1,2,3,4,5,6,

Recent research points out that there is growing evidence of changes in the brain with people with chronic pain.7

Chronic pain patients sometimes have a decreased cortical representation of the affected body parts8,9 - which in the case of LBP is also shown by diminished movement control.10

This means that when you want to make a movement without moving your back you are unable to do so, and instead you still move your back because you can't control it. This movement sometimes happens without you even noticing it.

Practicing movement control can lead to a better representation of your different body parts in your sensual cortex , which is a section in your brain that makes you feel your body surface.

Imagine a musician, they will have much better cortical representation of their hands than someone who has not acquired this coordinative skill. Your brain adapts to how you are using your body.

What some research suggests is: The better your body is represented in this part of your brain (and you can train this through movement control) the less pain you will experience if you are suffering from chronic pain.11,10,12,

Basic Anatomy for practicing movement control:

Your pelvis is connected to your thigh-bones as well as your spine. Therefore when you tilt your pelvis up or down, the position of your spine changes too.

It's also necessary to understand that the neutral position of your lower spine is a curved line (looking at it from the side). Keeping your lower back slightly curved during different exercises without moving it is often a goal in movement control.

A good way to start practicing movement control is to learn how to tilt your pelvis in different positions and become conscious of the resulting movement in your lower back.

Listen to the podcast, episode 05, "Movement Control" at www.mybackrecovery.com to learn more about movement control for people recovering from low back pain.

Videos:

find all the resources at: http://mybackrecovery.com/resources.page

watch the clip

• introduction

• quadruped - position

• supine

• side lying position

• seated

• standing position

• lean forward from a seated position without moving your back as a movement control exercise. If you do it correctly your back will not change its curvature while leaning forward, therefore the movement is coming from your hips.

• example test movement control

Literature:

1. Burton a K, Balagué F, Cardon G, et al. Chapter 2. European guidelines for prevention in low back pain : November 2004. Eur Spine J. 2006;15 Suppl 2(2006):S136-68. doi:10.1007/s00586-006-1070-3.
2. Raspe H. Gesundheitsberichterstattung Des Bundes - Rückenschmerzen. Heft 53. Berlin: Robert Koch-Institut; 2012.
3. Goertz M, Thorson D, Bonsell J, et al. Adult Acute and Subacute Low Back Pain. 15th ed.; 2012.
4. Acute A, Pain M, Group G. Evidence-Based Management of Acute Musculoskeletal Pain. Pain. 2003;370(9599):63-82. doi:10.1016/S0140-6736(07)61670-5.
5. Bernhard A, Bundesärztekammer, eds. Nationale VersorgungsLeitlinie Kreuzschmerz. Langfassun. Berlin: Ärztliches Zentrum für Qualität in der Medizin; 2015. doi:10.6101/AZQ/000250.
6. van Tulder M, Becker A, Bekkering T, et al. Chapter 3. European guidelines for the management of acute nonspecific low back pain in primary care. Eur Spine J. 2006;15 Suppl 2:S169-91. doi:10.1007/s00586-006-1071-2.
7. Wand BM, O'Connell NE, Di Pietro F, Bulsara M. Managing chronic nonspecific low back pain with a sensorimotor retraining approach: exploratory multiple-baseline study of 3 participants. Phys Ther. 2011;91(4):535-546. doi:10.2522/ptj.20100150.
8. Catley MJ, O'Connell NE, Berryman C, et al. Is tactile acuity altered in people with chronic pain? A systematic review and meta-analysis. J Pain. 2014;15(10):985-1000. doi:10.1016/j.jpain.2014.06.009.
9. Moseley GL. I can't find it! Distorted body image and tactile dysfunction in patients with chronic back pain. Pain. 2008;140(1):239-243. doi:10.1016/j.pain.2008.08.001.
10. Gutknecht M, Mannig A, Waldvogel A, et al. The effect of motor control and tactile acuity training on patients with non-specific low back pain and movement control impairment. J Bodyw Mov Ther. 2015;19(4):722-731. doi:10.1016/j.jbmt.2014.12.003.
11. Daffada PJ, Walsh N, McCabe CS, Palmer S. The impact of cortical remapping interventions on pain and disability in chronic low back pain: a systematic review. Physiotherapy. 2015;101(1):25-33. doi:10.1016/j.physio.2014.07.002.
12. Luomajoki H, Kool J, de Bruin ED, Airaksinen O. Improvement in low back movement control, decreased pain and disability, resulting from specific exercise intervention. Sports Med Arthrosc Rehabil Ther Technol. 2010;2(Mc):11. doi:10.1186/1758-2555-2-11.

This episode presents the different groups within low back pain and looks at where statistics come from. This information helps you battle fear associated with the condition and validate your experience of pain.

Facts about Low Back Pain (LBP)

LBP is defined as pain and discomfort below the costal margin and above the inferior gluteal folds, with or without referred leg pain.1

LBP is categorized into acute LBP and chronic LBP, which is LBP lasting for longer than 12 weeks.2,3,4,5,6

LBP is the most common form of chronic pain,7 a leading cause of disability in people younger than 45 years old8 and has a lifetime prevalence of 70 % in industrialised countries9.

LBP is among the top ten causes of long-term disability in every country and number one cause in 86 countries.10 LBP is the fifth most common reason for all doctor's visits in the United States11 and the third most common diagnosis in German prevention and rehabilitation facilities.12

One year after a first episode of back pain 62% of people will still experience pain while 16% of those initially unable to work are still not working.13

What Back Pain do You Have?

• 80-95 % non-specific LBP
• 5% radicular syndrome
• 1 % serious spinal pathology

What is Non-Specific LBP?

Today it is widely accepted that the biggest group of LBP is non-specific-LBP. Non-specific LBP means that no anatomic structure can be identified that is at fault. You might be surprised to learn that this is the case with 80-95% of all people with

LBP. 9,12,4,5,14,15

How Should it be Diagnosed?

Almost all guidelines16,17,6 recommend that people presenting with an acute episode of LBP should be screened for:

1. potential serious pathology (e.g. cancer, fractures, infections of the spine, cauda equina syndrome, systemic disease) that could cause pain in the back
2. radicular syndrome (that means pain arises from the nerve roots in your spine)

Potential serious pathologies for LBP are very rare (0,01% spinal infections, 0,7% cancer) and together with neurological impairment make up for approximately 1-5% of all LPB-Incidents.18

Nerve root pain (pain caused by the nerves in your spine) is considered to be present if there is pain radiating down the leg, together with a positive neurological examination (muscle strength, sensibility and deep tendon reflexes should be assessed). The neurological examination is positive when there is a palsy/weakness of a muscle in your leg that wasn´t there before, or if you experience incontinence or urinary retention that wasn´t there previous to your back pain, or if parts of your skin are numb.

If you have no confirmed serious disease and no radicular symptoms you have non-specific LBP.

For LBP with substantial neurologic involvement (1-5 %), guidelines generally do not recommend conducting any further assessment until appropriate conservative management (which is rarely defined) has failed, after which MRI or CT (imaging of your spine) is generally recommended.6

Find out more: www.mybackrecovery.com

Sources:

1. Duthey BB, Ph D. Priority Medicines for Europe and the World " A Public Health Approach to Innovation " Update on 2004 Background Paper Background Paper 6 . 24 Low back pain. (March 2013).
2. Airaksinen O, Brox JI, Cedraschi C, et al. Chapter 4. European guidelines for the management of chronic nonspecific low back pain. Eur Spine J. 2006;15 Suppl 2(November 2004):192-300. doi:10.1007/s00586-006-1072-1.
3. Savigny P Watson P, Underwood M, Ritchie G , Cotterell M, Hill D, Browne N, Buchanan E, Coffey P, Dixon P, Drummond C, Flanagan M, Greenough,C, Griffiths M, Halliday-Bell J, Hettinga D, Vogel S, Walsh D. KS. Low Back Pain: early management of persistent non-specific low back pain. London Natl Collab Cent Prim Care R Coll Gen Pract. 2009;(May):1-235.
4. Goertz M, Thorson D, Bonsell J, et al. Adult Acute and Subacute Low Back Pain. 15th ed.; 2012.
5. Acute A, Pain M, Group G. Evidence-Based Management of Acute Musculoskeletal Pain. Pain. 2003;370(9599):63-82. doi:10.1016/S0140-6736(07)61670-5.
6. Dagenais S, Tricco AC, Haldeman S. Synthesis of recommendations for the assessment and management of low back pain from recent clinical practice guidelines. Spine J. 2010;10(6):514-529. doi:10.1016/j.spinee.2010.03.032.
7. Froud R, Patterson S, Eldridge S, et al. A systematic review and meta-synthesis of the impact of low back pain on people's lives. BMC Musculoskelet Disord. 2014;15:50. doi:10.1186/1471-2474-15-50.
8. Lis AM, Black KM, Korn H, Nordin M. Association between sitting and occupational LBP. Eur Spine J. 2007;16(2):283-298. doi:10.1007/s00586-006-0143-7.
9. Burton a K, Balagué F, Cardon G, et al. Chapter 2. European guidelines for prevention in low back pain : November 2004. Eur Spine J. 2006;15 Suppl 2(2006):S136-S168. doi:10.1007/s00586-006-1070-3.
10. Global Burden of Disease Study 2013 Collaborators. Global, regional, and national incidence, prevalence, and years lived with disability for 301 acute and chronic diseases and injuries in 188 countries, 1990-2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet (London, England). 2015;6736(15):1990-2013. doi:10.1016/S0140-6736(15)60692-4.
11. Cowan P. Consumer Guidelines for Low Back Pain. (Kelly N, Chou R, eds.).; 2008. http://theacpa.org/condition/back-pain.
12. Raspe H. Gesundheitsberichterstattung Des Bundes - Rückenschmerzen. Heft 53. Berlin: Robert Koch-Institut; 2012.
13. Hestbaek L, Leboeuf-Yde C, Manniche C. Low back pain: what is the long-term course? A review of studies of general patient populations. Eur Spine J. 2003;12(2):149-165. doi:10.1007/s00586-002-0508-5.
14. Bernhard A, Bundesärztekammer, eds. Nationale VersorgungsLeitlinie Kreuzschmerz. Langfassun. Berlin: Ärztliches Zentrum für Qualität in der Medizin; 2015. doi:10.6101/AZQ/000250.
15. van Tulder M, Becker A, Bekkering T, et al. Chapter 3. European guidelines for the management of acute nonspecific low back pain in primary care. Eur Spine J. 2006;15 Suppl 2:S169-S191. doi:10.1007/s00586-006-1071-2.
16. Pillastrini P, Gardenghi I, Bonetti F, et al. An updated overview of clinical guidelines for chronic low back pain management in primary care. Jt Bone Spine. 2012;79(2):176-185. doi:10.1016/j.jbspin.2011.03.019.
17. Koes BW, van Tulder M, Lin C-WC, et al. An updated overview of clinical guidelines for the management of non-specific low back pain in primary care. Eur Spine J. 2010;19(12):2075-2094. doi:10.1007/s00586-010-1502-y.
18. Jarvik JG, Deyo RA. Diagnostic evaluation of low back pain with emphasis on imaging. Ann Intern Med. 2002;137(7):586-597. doi:10.7326/0003-4819-137-7-200210010-00010.