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MRI Back Scans Do Not Predict if You Need Surgery

This is an article written By Richard C. Senelick, M.D. in regards to MRI Scan and their indications for surgery that is well worth reading

Deep aching back pain that you feel all the way down into your leg. You wake up with it, or it shows up with a simple sneeze or when you bend over to tie your shoes. This problem, called sciatica, affects 13 to 40 percent of all people during their lifetime and costs our economy approximately $50 billion each year. Only headaches are a more common neurologic ailment.

In most cases, the leg pain and most severe symptoms resolve in eight weeks, but we are not a patient society. Many of the people who have sciatica symptoms go on to have back surgery that may or may not solve the problem. Despite changes in technology and fancy titanium screws, plates and cages, the overall results of surgery have not significantly improved over the last few decades. This over-prescription of surgery is a huge problem.
MRI Scans of the Back

The introduction of MRI scans in the 1980s resulted in elegant pictures of the lumbar spine and graphic demonstrations of the deterioration that happens to our spines as we age. It is one thing to look in the mirror each morning and see the wrinkles that slowly form at edges of your eyes and mouth. It is another thing to have your doctor suddenly show you a picture of your spine with its bony growths, deteriorated disks and endangered nerve roots.

When throbbing back and leg pain attack your brain’s pain centers, it is easy to say, “I will do anything to get rid of this pain. Where is the surgeon?” But, a recent study in the New England Journal of Medicine looks at whether an MRI scan can predict whether you need surgery or whether you are better off taking your time and following an extended course of conservative treatment. Having an MRI of your lumbar spine performed may be quick and painless, but it can lead to unneeded surgeries, complications, poor outcomes and chronic pain. The 15-20 percent of people who have recurrent episodes of sciatica will have even more MRI scans and repeatedly face the decision of whether to have surgery.

Researchers at multiple centers recruited 283 patients with persistent symptoms of sciatica (symptoms that had lasted 6-12 weeks) and randomized them in a study comparing early surgery versus prolonged conservative therapy. All of the patients had a herniated disk on their MRI scans, and scans were performed at the beginning of the study and one year later. The question was whether there is an association between what we see on the MRI scan and the eventual clinical outcome. Did the pain go away, and was the patient happy with the outcome?
Herniated Disks Can Disappear!

At one year, 84 percent of all the patients had a favorable outcome whether they had surgery or conservative treatment. Previous studies had reported that those who have surgery may get better faster, but at one year there is no difference. The disk pressing on the nerve root is thought to cause the pain down the leg, and it disappeared on the MRI scan in 82 percent of people having surgery. But, it also disappeared in 60 percent of those who had conservative therapy.

This shows that herniated disks get smaller and disappear even without surgery! The study also looked at those patients who still had a disk herniation on their MRI scan at one year, and once again there was no significant difference. Eighty-five percent of those with a disk herniation on their MRI scan at one year still had a favorable outcome, as compared to 83 percent with no disk herniation.

Of course, it is not so simple as to just assume that something is pressing on the nerve and causing the pain. How many times have you heard someone say that they had a “slipped disk” that their chiropractor put back in place? It sounds good, but it doesn’t work that way. It may be inflammation, a chemical reaction or some other process that causes the pain. The truth is that the source of a person’s low back and leg pain is frequently illusive.
The bottom line: When trying to decide who should have surgery, a herniated disk or nerve root compression on a MRI scan does not predict a better outcome. This study even looked at those situations where a piece of disk has broken off (an extrusion) and there was no difference. It is difficult to correlate a patient’s symptoms with the findings on their MRI scan.

5 Guidelines to Follow

If a MRI scan does not distinguish between a favorable and unfavorable outcome, how should a doctor and patient make the decision on whether to have surgery? Here are the five guidelines that have served me well over the years.
1. You have persistent pain that you can no longer tolerate, and it is unresponsive to medications, physical therapy and a prolonged period of conservative therapy. Give it time.

2. The planned surgery correlates with the anatomic location of your symptoms. For example, your back hurts, so you think that means you should have surgery on your back. Far too many times I have seen patients have surgery on an area that is unrelated to the location of their complaints. Surgery that is performed for low back pain without leg pain is fraught with difficulties.

3. If you have “progressive” weakness, this may suggest that the there is increasing pressure on the nerves that needs more immediate attention. Weakness, in and of itself, is not an absolute indication for surgery.
4. Many people have numbness, tingling or some loss of sensation in their leg. This does not automatically require surgery and frequently does not resolve with surgery. The key here is whether you have a progressive loss of sensation or a sudden change that needs immediate attention.

5. The rapid onset of bladder or bowel symptoms may be a neurological emergency that needs immediate surgery. If you have chronic back or leg symptoms and then develop problems urinating, this needs immediate attention.
The next time your are lying on your back, encased in a MRI machine making clanging and banging sounds from another world, keep in mind that the amazing pictures your doctor will show you of your back are only part of the story. Remember that there is no such thing as “good as new.”
For more by Richard C. Senelick, M.D., click here.

If you are experiencing pain, take action to eliminate it! We can help. Let us help you get back to the activities you enjoy. Call 804 320-2220 and setup an appointment today.

Filed Under: Physical Therapy, Spine Rehabilitation, Sports Medicine Tagged With: back pain, http://www.optimalsolutionspt.com/blog/wp-admin/post.php?post=53&action=edit#, manual therapy, spine rehab

Back Pain in Golfers

Back Pain is a common problem in the general population and in golfers. I have included an recent article written by Dr. Greg Rose from the Titleist Performance Institute in full length. It illustrates very well what we teach and work to address everyday in our patients who have back pain. This article is directed at golfers, but it applies to all of us in everyday life as well as other sports. I hope you enjoy the article it is well worth the time to read and understand it. If you are a golfer and have current injury of simply want to improve your game, we can help! Our therapists are trained and certified through the Titleist Performance Institute. We offer golf specific evaluations and corrective training programs to prevent injury and improve your game. Let us help you stay on par from tee to green!

The Golfer’s Guide to Lower Back Pain – Part 1
• By Dr. Greg Rose from Titleist Performance Institute

Lower back pain is by far the most common ailment suffered by golfers of all ages. Based on data collected at TPI from over 31,000 golfers, 28.1% of all players deal with lower back pain after every round. Lower back pain is also the most common complaint seen amongst professional golfers on all tours (data suggest over 23% play with lower back pain). To understand the cause of lower back pain, it requires a thorough investigation of what I call the “Body-Swing Connection”. Let’s take a closer look.

First of all, let me start by making a bold statement. The lower back is rarely the original cause of the pain! It may be the current source of the pain, but it’s rarely the cause of the pain. More often than not, abnormal motions or forces coming from adjacent or distant areas of the body force the lower back to do excessive work until it completely breaks down itself. In other words, the lumbar spine is usually the area that is being unnecessarily overworked to the point of injury. It is basically the over-used and over-abused worker who just goes and goes until he or she breaks.
In my experience, the lack of mobility seen in the ankles, hips, thoracic spine and shoulders of many golfers forces the lower back to carry all of these excessive loads and is the primary cause for most back injuries. So any article about lower back pain should address those areas specifically.
When the lower back finally does break down, you can typically expect one of the following conditions to occur:

1. Muscle Strain or Ligamentous Sprain – A muscle strain or “pulled muscle” as well as an injured ligament will usually resolve itself in 2-4 weeks with plain old rest and recovery. However, there can be some residual muscle stiffness, fascial restrictions, joint fixations or movement alterations that may need to be addressed afterwards. Sprains or strains are the most common form of lower back injury we see. Symptoms may range from a minor ache to a sharp debilitating pain. Most sprains and strains are localized in the lower back region, meaning pain does not radiate into the butt or leg. The chemical inflammation around the injury is usually sore to the touch and the pain usually subsides with rest.

2. Disc Injury – The lumbar intervertebral disc acts as a spacer between adjacent vertebrae to help absorb compressive forces and create space for the spinal nerves to exit the spinal column. Imagine the disc as a jelly filled donut. If excessive or abnormal stressors are placed on the disc, tears can occur. When this happens, the force of the jelly against that tear can cause a bulge in a portion of the donut leading to a “bulged disc.” In more severe cases, the jelly can actually exit through the donut wall leading to a “ruptured disc.” The discs are also susceptible to degenerative changes over time. To continue the analogy, imagine the jelly inside of the donut drying up. Any of these disc problems can leave the spinal nerves vulnerable to irritation or compression resulting in dysfunction and pain. Most disc pathologies create radiating pain into the buttocks or the leg (think sciatica) due to the irritation of spinal nerves. Sitting for prolonged periods of time, bending forward into a slouched position, or lifting heavy objects can all exacerbate disc symptoms.

3. Altered Joint Mechanics or Motor Control – Interestingly, the brain can completely change the lumbar spine’s ability to move just by changing which muscles are firing or by altering the sequence of when muscles fire. This can occur in the absence of any visible injury. These altered motor control or joint mechanics can begin as a protective mechanism, but can lead to chronic problems over time. Most experts believe over 80% of all chronic lower back problems begin this way.

4. Degenerative Arthritis – Just like all joints, with over-use, abuse, or even lack of use, spinal joints can become arthritic. Bone spurs and osteophytes act like stalactites and stalagmites inside a cave closing in on the opening for the spinal nerves. With time, these bony outgrowths can fuse joints, irritate nerves and create general inflammation in the area. Stenosis, the narrowing of the canal or cave that houses the spinal nerves is a very common problem with arthritic changes. Most arthritic problems in the spine create sharp pain with certain movements. The resulting inflammation can then cause chronic dull pain over time.

5. Bone Fracture – Stress fractures and pedicle fractures (spondylolysis) are common problems seen in the lumbar spines of rotational athletes. This occurs due to the rapid extension and rotation of the spine, causing adjacent vertebrae to collide into each other at their end range of motion. This action places high forces on the posterior portions of the vertebrae and can lead to these types of fractures. Injuries of this sort can lead to deep dull pain and instability in the spine.

So the big questions are:
• How do I prevent the lower back from getting injured?
• How do I treat the injury once it occurs?

Let’s start by talking about prevention. The best way to prevent lower back injuries in golf is to attack the problem head on with three main offensives:
• Normalize Movement Patterns
•Optimize Swing Mechanics
• Incorporate Recovery Techniques

Normalize Movement Patterns
The first line of defense against lower back pain is to create optimal movement patterns in the areas directly above and below the lumbar spine – the hips and thoracic spine. The golf swing requires great rotational mobility to develop and transfer energy to the club. That mobility should come from the joints in the body that are designed to rotate, the hips and the thoracic spine. If you study the anatomy of the lumbar spine, you will see that the spinal joints, called facets, are orientated to allow flexion and extension, not rotation. If the lower back is forced to be a primary rotator due to a lack of hip and thoracic mobility, it’s only a matter of time before an injury will occur in the lumbar spine. It is important to remember that the hips and thoracic spine do not operate in isolation. Abnormal motion in the ankle can cause poor hip motor control. And poor motion in the shoulder can cause poor thoracic spine motor control. Therefore, we can’t neglect the ankle or shoulder joints in our assessments.

So in order to unravel the mystery of why someone has lower back pain, we must first evaluate the movement patterns of all the surrounding areas. At TPI, we use a combination of our basic TPI assessment screen and the SFMA (Selective Functional Movement Assessment) to identify any of these altered movement patterns and make a true starting diagnosis. Once the dysfunction has been identified, we attack all mobility restrictions first and then create the stability required to normalize motor control. When the areas above and below the lumbar spine are functioning properly, the lumbar spine can gain some much-needed rest. Once normal movement patterns are optimized, a solid conditioning program is the best form of prevention. We encourage all players to build a solid base of strength and to maintain proper mobility in order to keep their lower back healthy for a lifetime.

Optimize Swing Mechanics
When it comes to optimizing swing mechanics, it is easy to see how some common swing characteristics can induce abnormal stressors into the lower back. The most common characteristic is Reverse Spine Angle (RSA). This is usually caused by a lack of rotary mobility in the hips and thoracic spine causing the lumbar spine to extend excessively in order to pick up some much needed range of motion. Because RSA puts excessive extension in the spine at the top of the backswing, the player must excessively flex and right side bend to get back to impact, a bad combination. This combination of movements has been proven to add compressive and shear stress to the lumbar spine. My saying for Reverse Spine Angle goes like this, “It’s not if you’re going to get lower back pain, it’s when are you going to get lower back pain!” Learn more about Reverse Spine Angle below.

The second most common swing characteristic that can lead to lower back problems is S-Posture. This is typically a set-up problem and often begins before the player even takes the club back. S-Posture places the lumbar spine into something called the Lower Crossed Syndrome Pattern. This is an extremely common postural adaptation to muscle imbalances created by prolonged static postures, like sitting at a desk for years on end. With Lower Crossed Syndrome, the abdominal and gluteal (stomach and butt) muscles become inhibited or weak due to over-activation or tightness in the hip flexors and lower back. Due to this imbalance in the muscles surrounding the lumbar spine, excessive stress is placed on the structures of the lower back. S-Posture also helps encourage Reverse Spine Angle since the lumbar spine is already excessively extended at the start of the swing. Learn more about S-Posture below.

The third most common swing characteristic that can lead to lower back issues is called Hanging Back. Hanging Back can force a player to excessively right side bend through impact. This can put added stress onto the right side of the lumbar spine and lead to lower back injuries. Some players hang back or add right side bend in an attempt to open the clubface through impact. This is a very common compensation for a closed clubface in the golf swing. Additionally, many players with lower back pain can become tentative in their swing and may exacerbate the problem by not properly shifting weight forward in the downswing, hanging back instead. Learn more about Hanging Back below.

As you can see, a thorough evaluation of a player’s swing mechanics is imperative in order to properly understand the injury mechanism. We always combine our physical exam with a swing exam to try and make this “Body-Swing Connection.”
Some of the most common swing modifications that we recommend for eliminating back pain are the following:

1. Neutral Posture – Now that you understand how Reverse Spine Angle and S-Posture can lead to lower back injury, it is easy to see how getting a player into a neutral spine posture can dramatically help stabilize their spinal mechanics. See below our favorite set-up drill for neutral posture: Neutral Pelvis Forward Bends. Maintaining a neutral spine posture during the backswing is also critical. Many players go into excessive extension in the lumbar spine mid-way through the backswing and then continue that extended position into the top of the swing (creating Reverse Spine Angle). Below is our favorite drill to help prevent that pattern: Pubic Bone to Rib Cage

2. Lead Hip High – One of the easiest ways to encourage a Reverse Spine Angle is to allow the player to set up with their trail hip higher than their lead hip. If a right-handed player gets their right hip higher at set-up, it tends to encourage a lateral sway away from the target in the backswing, which usually tilts the spine towards the target at the top of the swing. The goal of all players with lower back pain should be to set up with a level pelvis or the lead hip slightly higher than the trail hip. Below is our favorite drill to assist with this: Lead Hip High Lead Shoulder Low

3. Forward Ball Position – Players who Hang Back or who have Reverse Spine Angle tend to place the ball back in their stance. To eliminate this, exaggerate a forward ball position. This will encourage the player to shift weight forward and not hang back during the downswing. This forward weight shift is a key move that can reduce the amount of right side bend through impact.

4. Eliminate the Sway – As stated earlier, any movement away from the target (Sway) in the backswing, can lead to Reverse Spine Angle at the top. To help eliminate a sway try this drill below: Reach Over the Fence.

Neutral Pelvis Forward Bends

Pubic Bone to Rib Cage

Lead Hip High Lead Shoulder Low

Reach Over the Fence

Incorporate Recovery Techniques
The last form of preventative action that should be encouraged is incorporating recovery techniques into a player’s normal after-round routine. Recovery techniques will help reduce inflammation, restore normative motor control and repair muscle and joint damage sustained during the round. Basic forms of recovery include the following:
Hot and cold therapy – This includes ice packs, cold plunges, cryotherapy, heating pads, hot packs, hot tubs, sauna, steam rooms, etc. All of these methods can help make a difference after a round. Experimentation with alternative methods may be necessary to find the best combination for each player.

Massage – This is one of the best ways to reduce soreness, flush inflammation and revitalize the soft tissue.

Nutritional Support – There are many nutrients that can help reduce soreness, repair muscle damage and control inflammation. After four or five hours of playing golf, the body is in a slightly depleted and catabolic (tissue destructive) state. At this time, it is critical to eat the right type of foods to help facilitate recovery of muscles, tendons and ligaments. A player can feel dramatically better the next day by simply adding a post round recovery shake or incorporating proper dietary recommendations. We encourage players to immediately replenish their carbohydrates to help reduce soreness and to add some protein to help repair muscle and tendon damage. Drinking plenty of water is also a great recovery technique. Dehydration after a round can lead to next day soreness and muscle fatigue.

Sleep – One of the most important recovery techniques that I can’t stress enough is a minimum of eight hours of sleep. This is when the body repairs and rebuilds. Without that necessary sleep, most players will wake up sore.
Recovery Exercise – Many exercises can help aid recovery. Stretching is a great example of an exercise that can help re-establish normal motor control after a round.
Now let’s shift our attention to some actions that can be taken if, unfortunately, you already have a lower back injury. I will discuss each of the major types of injuries and options available for treatment. Remember, the preventative actions discussed above should also be incorporated into the treatments below.

Muscle Strains
Treatment of muscle strains should focus on controlling the initial inflammation and restoring proper muscle, joint and ligamentous function. Typical treatment protocols include some combination of the following:

Manual Therapy – Chiropractic, physical therapy, osteopathy, massage, and other manual therapy techniques can be extremely effective in reducing the recovery time for muscle strains and ligamentous sprains. These options help promote proper blood flow in the lower back (to help with healing), loosen tight lower back muscles, maintain proper joint mechanics, and aid in the release of endorphins, the body’s natural painkillers. All of these things promote accelerated healing in the lower back.

Cold Therapy (Cryotherapy) – The application of cold packs over the injured area can dramatically help numb the tissues and may relieve muscle spasms or associated inflammation. Cold can be applied using an ice or gel cold pack, cold plunge pools, cryotherapy chambers (which use liquid nitrogen to cool the room) or topical sprays (such as ethyl chloride) that cool by evaporation. Do not apply cold to tissues with an already reduced blood supply (for example, when the arteries are narrowed by peripheral arterial disease).

Electrical Stimulation – Electrical stimulation via electrodes placed on the skin has been used to help speed recovery for years. Electrical stimulation can increase nervous system activity and stimulate fluid circulation resulting in reduced inflammation. One form of electrical stimulation called transcutaneous electrical nerve stimulation (TENS) uses a low current that does not cause muscles to contract. The device produces a tingling sensation but is not painful.

Heat Therapy – Heat increases blood flow and can temporarily decrease joint stiffness, pain, and muscle spasms. Hot packs, infrared heat, paraffin baths, and hydrotherapy provide surface heat. High-frequency sound waves (ultrasound) can also be used to generate heat in deep tissues.

Acupuncture – This involves treating various points on the body using several methods such as the insertion of thin needles, application of heat, applying pressure or laser light therapy. Traditional acupuncture involves needle insertion, moxibustion (burning of a Chinese herb) and cupping therapy. This is a fundamental component of traditional Chinese Medicine (TCM) that has been used for over 5,000 years. According to TCM, the stimulation of specific acupuncture points corrects imbalances in the flow of Qi (chi) through channels known as meridians. By balancing the body’s qi, healing is accelerated. Acupuncture should be done by a certified acupuncturist and with sterile needles.

Rest & Recovery – Often, muscle strains just need a few days of TLC. However, when I say rest, I don’t mean someone should remain 100% bedridden. Reduction of workload, not lifting heavy objects, time off from strenuous activities, improvement in workplace ergonomics and modification of poor sleeping habits can usually do the trick. The body has an amazing ability to heal sprains and strains as long as you stop aggravating it. Just remember, light activities such as walking can be very beneficial in accelerating the recovery process.

Anti-inflammatory Medication – Local inflammation that may exacerbate pain can be reduced with the aid of anti-inflammatory medication such as ibuprofen or NSAIDs. Just remember, these medications only reduce the inflammation and do not fix any potential muscle or ligamentous damage that may lie below the inflammation. Be warned, chronic use of NSAIDs can become part of the problem and not part of the solution.
Muscle Relaxants – If muscle spasms are present (which are often associated with muscular strains) these drugs may relieve some of the pain associated with the muscle spasms.

I am not a fan of including the anti-inflammatory or muscle relaxant medications unless it is absolutely needed. If the pain can be tolerated, I feel some of the normal associated inflammation can help speed up the recovery.

Once the pain has subsided, we must investigate why the injury occurred in the first place. In other words, there is usually some underlying altered movement pattern that caused the sprain or strain to happen. We go back to our basic movement screen and the SFMA to make sure the original cause of the problem has been addressed as well as the resulting sprain and strain.

Disc Injuries (Non-Surgical Options)
As we discussed earlier, the intervertebral disc resembles a jelly filled donut. All of the treatment options below focus on reducing the irritation or compression to the spinal nerves created by the abnormal displacement of the jelly. Here are the most common options:

Conservative Rehabilitation – The first line of treatment should always involve a 6 to 12 week trial of either chiropractic, osteopathic, and/or physical therapy. The goals of these types of treatment are to:
• Reduce the inflammation
• Restore normal stability, motor control and motion in the lumbar spine
• Improve mobility in the surrounding joints (hips and thoracic spine)
• Educate the patient on techniques to prevent further episodes such as ergonomics, sleeping positions, proper lifting and carrying techniques, recovery options, etc.

• Supply the patient with an exercise routine to prevent re-injury
Most patients will feel some sort of relief right away. Many successful rehabilitation programs include a combination of many conservative techniques.

Acupuncture – I covered this form of treatment earlier. Personally, I’ve had many patients with disc issues feel significant relief following acupuncture treatments.
Home Distraction – Many people are familiar with “the rack” which was used to stretch people apart as a torture device in medieval times. Well, this is kind of like that, but without the torture part. Often, the nerve pain can be decreased by reducing the compressive forces applied to the vertebrae above and below the disc. Imagine stepping on a jelly donut, shooting the jelly out of the outer wall. If you just take your foot off the donut (thus reducing the pressure), it should stop forcing the jelly out. Home distraction techniques like the types listed below work similar in theory to that.

• Lumbar distraction devices – These are devices that allow the patient to lay down (face up) and separates the upper and lower body. Typically, these devices use some form of air pump or electric motor to slowly increase the amount of distraction to an appropriate tolerance level.

• Inversion devices – Hanging upside down is an age-old technique that can offer relief to some back pain patients. With this form of distraction, the normal compressive forces of gravity are completely reversed in the inverted position.

• Brachiating – Similar in concept to inversion devices but instead of hanging upside down, the patient simply holds onto a pull-up bar with both hands and lifts their feet off the ground. The weight of the patient’s lower body acts as the traction mechanism and helps separate the lower body from the upper body. A weakness with this method is the patient’s own upper body strength, as the patient’s individual ability can limit the amount of time they can support themselves in the hanging position.
Heat and Cold Therapy – As stated earlier, heat and cold therapy can temporarily decreases inflammation, joint stiffness, pain, and muscle spasms. Hot packs, infrared heat, paraffin baths, hydrotherapy and high-frequency sound waves (ultrasound) can all be used in the application of heat. Ice, gel cold packs, cold plunge pools, cryotherapy chambers or topical sprays can all be used to chill the area.

Anti-Inflammatory Drugs – Most disc episodes create swelling around the spine therefore, inflammation is a major contributing factor to the pain. Anti-inflammatory medications such as non-steroidal anti-inflammatory drugs (NSAIDs) are often an effective pain medication treatment option. As stated earlier, this only reduces the inflammation and does not fix the inherent problem that lies below the inflammation.
Epidural Injections or Medrol Dose Pack – If the NSAIDs don’t offer relief, either oral steroid medication (Medrol) or an epidural injection around the disc site usually achieves an immediate anti-inflammatory effect. Approximately 50% of the time, an epidural steroid injection will give pain relief that may last from one week up to one year. Most physiatrists recommend a maximum of three epidural injections per calendar year (at least two weeks apart).

Disc Injuries (Surgical Options)
The options for surgical treatments are varied and new experimental treatments are constantly under development as technology advances. The following are the most common surgical options offered today for lumbar spinal pain.

Micro-Discectomy – This is surgery to remove the herniated disc material that is pressing on a spinal nerve root or the spinal cord. Most of these procedures are done today as a micro-discectomy, which uses a special microscope to view the disc and nerves. These tools allow the surgeon to use a smaller incision with minimal or no damage to the surrounding supporting structures. Down time is usually minimal with these procedures and recovery is usually very good. Here is a review of spinal surgery results that looks at the return to athletic activities from some of the foremost spinal surgeons in the country, click PDF below:

Laminectomy – Sometimes, before a discectomy, a small piece of bone (the lamina) from the affected vertebra may be removed. This is called a laminotomy or laminectomy and enlarges your spinal canal to relieve pressure on the spinal cord or nerves and may allow the surgeon better access to the problem area.

Spinal Fusion – When the joint between the two vertebrae is very arthritic or the joint is very unstable, a surgeon may recommend a fusion. A spinal fusion surgery is designed to stop the motion at a painful vertebral segment, which in turn should decrease pain generated from the joint. Often, a bone graft is added to a segment of the spine that will eventually fuse the two vertebrae together. This procedure has a much longer down time, since the patient must wait for the fusion to take and heal.

Disc Replacement – The last and most recent option available is a total disc replacement. This procedure involves replacing the body’s natural disk with an artificial replacement made of metal or a metal/plastic combination. Lumbar disc replacement gained FDA approval in 2004.¬ I have seen some incredible results from this form of treatment and I’m encouraged about future advancement in this option.

In Part 2, I’ll take a closer look at the remaining lower back conditions including altered joint mechanics & motor control, degenerative arthritis and bone fractures. Additionally, I’ll provide some return-to-play protocols and guidelines for those players working through lower back injuries or discomfort.

If injury of pain is hampering your lifestyle and adversely effecting your game, we can help! Give us a call and set up a Titleist Performance Institute Golf Fitness Assessment and or physical therapy evaluation today!

Here is Link to complete article
http://www.mytpi.com/articles/health/the_golfer%27s_guide_to_lower_back_pain_part_1)

Presented by your team at Optimal Solutions Physical Therapy Inc.

Filed Under: Functional Training, Manual Therapy, Physical Therapy Tagged With: Addressing Pain, Back Pain Rehabilitation, Clarke Tanner PT, golf and back pain, Golf Fitness Assessment, Golf injuries, http://www.optimalsolutionspt.com/blog/wp-admin/post.php?post=53&action=edit#, manual therapy, Optimal Solutions Physical Therapy, spine rehab, Sports injuries, Titeist Performance Institute

Back Pain and the Healing Process

Many of us have experienced a sprained ankle before. Typically, when the ankle is injured, it swells, stiffens, and is painful. Walking becomes difficult, and the ankle is weak. The ankle feels vulnerable for a while but, in time, returns to normal (it frequently doesn’t regain full mobility, which can contribute to problems later on, but this is another blog topic). Generally, we don’t worry too much about a sprained ankle because it eventually does well and rarely results in significant long-term disability. A testament to this is that there are few books and research articles written on chronic dysfunctional ankles and their impact on disability. In contrast, many books have been written and studies done on chronic back pain and its high rate of disability. Why the difference?

Anxiety, an emotional response to injury and pain, may be partially to blame. The anxiety level surrounding back injuries tends to be much higher than with ankle injuries. There are many reasons for this. The first consideration is, what is injured? Is it muscles, ligaments, disc? The cause is not easy to determine. Back pain is recognized to be 80% idiopathic, or of unknown cause. Moreover, there are many fear inducing words to describe the origins of back pain including a slipped disc, herniated disc, compressed nerve, and ruptured disc. These labels can be scary and unsettling when not understood. Many of the preceding diagnoses are common findings in individuals with no current/past history of back pain, and are not indicative of how well they will do in the future.

Additionally, back pain is a prevalent, debilitating ailment. Most of us know someone with back pain and its impact on quality of life and disability. This awareness adds to anxiety and the fear of what could happen in the future from a back injury. In addition, the media deluges us with references to back injuries and pain. From the outset, the possibility of prolonged problems is a concern. As mentioned in my previous blog, anxiety, fear, and worry about an injury add to the body’s inflammatory response and stress levels, thereby increasing pain experience. This exacerbates the problem. Fear and worry are not helpful responses unless they cause you to take a necessary action.

Although some tissues have better recuperative abilities than others, symptoms, and the physiology of injury, are similar in regards to the healing process. Tissues are damaged; a chemical inflammatory process ensues, which results in pain and swelling. The body then progresses through the healing process, and tissues gradually strengthen, becoming more stress tolerant. Through the rehab process, we work to insure healing, to help the patient regain mobility, strength, muscular control, and efficient movement patterns. With the preceding accomplished, the tissues and nervous system can return to normal, allowing for physical activity without pain. This is true of injured tissues in the ankle and the back.

We suggest considering all injuries, including back injuries, to be like an ankle sprain. Understand that when you injure your back, regardless of the tissue, it needs a chance to heal. Stress minimization and a period of protection to the tissue are necessary for optimal healing. Ankle sprains are easier to treat; we can splint, brace, or put you on crutches. However, with the back, we have to rely on reducing stress to tissues by avoiding painful activities, changing positions frequently, and doing your daily tasks with good position/efficient technique (no slouching on the couch!).

Working on regaining necessary attributes such as mobility, strength, muscular control, and efficient movement patterns is important in reducing your pain level and ability to be active without difficulty. Understand that your symptoms will be up and down as you work through the healing process. Likewise, occasional discomfort is not uncommon and should be expected. Last, but not least, work on your nervous system by having strong, positive thoughts. Be patient and stay in the present; do not project pain or problems into the future. Be confident you will heal. Affirm that you are healthy and strong in body and mind.

If you have a degenerative condition or pathology, there is still improvement possible. Commit to leading an active life. Complete elimination of pain should not be your goal. Success can be achieved by being active and doing what you enjoy.

By Clarke Tanner, PT, MPT, CMPT, ATC, CSCS and your OSPT Team

If you are experiencing pain, take action to eliminate it! We can help. Let us help you get back to the activities you enjoy. Call 804 320-2220 and setup an appointment today.

Filed Under: Physical Therapy, Spine Rehabilitation Tagged With: Back Pain Rehabilitation, Clarke Tanner, http://www.optimalsolutionspt.com/blog/wp-admin/post.php?post=53&action=edit#, manual therapy, Optimal Solutions Physical Therapy, pain management, physical therapy, PT, spine rehab

Understanding Chronic Pain and How to Eliminate It

Recent research into chronic pain states has revealed a variety of interesting facts. Pain is our body’s protective mechanism to prevent injury. For example, when you place your hand on a hot stove, you feel immediate pain, which prompts you to quickly pull your hand away, hopefully in time to prevent a burn! Likewise, when a person has continued to irritate a condition by repeated injury or continued repetitive stress, his or her nervous system can become “sensitized”, meaning the body learns to carry a pain signal because the circuit has been continually reactivated. The degree of stimulus needed to activate the signal gradually lessens to the point that non damaging stress to the body can result in pain. Your body’s protective mechanism becomes less accurate in assessing what is damaging and what is not.

Emotions, beliefs, stress level, and fears can help or hurt the healing process. Negative thoughts, called “catastrophizing “ in medical literature, include such behaviors as worrying about something serious being wrong, fears of what this could mean in the future, or focusing on your pain level. When catastrophizing, a stress hormone cortisol level is increased, pain thresholds are lowered, and circulating inflammatory mediators in the blood are increased (R.R. Edwards et al. / Pain 140 (2008) 135–144). The result is you hurt more and your body’s inflammatory response is increased. Your alarm system becomes hyperactive, and usual daily activities can become painful, prompting the individual to be less active. This can lead to fear of movement/activity, disuse, and de-conditioning, making your tissues less healthy and, therefore, less tolerant of stress, thus perpetuating the cycle. This can be a slippery slope, leading to decreased quality of life and/or depression.

For anyone experiencing pain over time, part of the rehab process is to address and encourage not only healing of unhealthy tissues but also calming the individual’s nervous system. There are good resources available to better understand this process including a book called “Explain Pain” (Butler D. and Moseley L. Noigroup Publications; in 2003). We have found that education and understanding are key components in successfully assisting individuals through the rehabilitation process. All injuries, not just long term chronic pain states, frequently have components of abnormal pain physiology that contribute to their perpetuation. We have found the following general advice helpful to our patients in resolving acute and chronic pain:

1. Understand what is contributing to the perpetuation of your pain and what you can do to minimize it. Are you overstressing your tissues throughout the day with bad postural habits and a poorly setup workstation? If so, change it and improve the situation. View the following link to correct your work station and sitting alignment http://www.youtube.com/watch?v=cHelFza49K8
2. Understand what happens to a nervous system that suffers chronic pain. Know that your body’s “alarm system” may not be an accurate assessor of what is damaging to your tissues. Discuss with your therapist how to tell the difference between good and bad pain.
3. Try to ease your worry that something more serious may be wrong. Talk about your concerns, fears, and symptoms with your therapist. If there is something that warrants further investigation he or she can help direct you. Worry is only helpful if it causes you to take a necessary action. Otherwise, it increases your inflammatory response and pain level for no good reason.
4. Do not focus on your pain. I am not saying to always ignore your symptoms, especially when you have done something that may have exacerbated your condition. However, constant vigilance of your pain level has been shown to decrease your pain threshold and increase your body’s inflammatory response, making you feel worse. Divert your attention elsewhere and enjoy your day.
5. Try to stay in the moment. If you are having pain, do your best not to project into the future how you will feel later today, tomorrow, or how it may impact you as time passes. Be confident you will heal and that your symptoms will pass. A positive attitude and belief that you will do well is one of the most important factors contributing to how well you will do in the future.
6. Remember, part of eliminating pain and working through the rehab process is to make you healthier from a global perspective. What are your specific needs and biggest deficits? Do you need healthy diet? More sleep? Do you do dissipate stress poorly? Do you exercise regularly? Do you have personal relationships that need attention? Are you in a stressful work setting? Poor organization skills, etc.? Work on your areas that need attention. A helpful book that everyone should read in this area is Spontaneous Healing, by Dr. Andrew Weil
7. Breathing and meditation activities have repeatedly been shown to reduce stress, improve health, and reduce pain states. Discuss this with your clinician.
8. Get more sleep than you think you need.
9. Do something for youself that you enjoy everyday.
10. Do something kind for someone else every day. You will get more benefit from it than they will.
11. Try to laugh as much as you can! It reduces stress and things seem to hurt less when you do.
12. Try to learn something new every day. When your focus is elsewhere pain is less.
13. Do some form of cardiovascular exercise regularly that will not exacerbate your condition. It is theorized to dissipate inflammation and is the strongest producer of natural endorphins (happy chemicals) we know of that are helpful in reducing pain.
14. Work on your prescribed exercise program and movement strategies learned in physical therapy. This is a key component! The cliché is true that you will get out of it what you put into it.
15. When adding new physical activities, do so in a slow, graded manner. This allows your tissues and nervous system to adapt without setting off the alarm system causing pain.
16. Have a plan and carry it out.
17. You have the key to healing yourself. Professionals are your guide through the process!

By Clarke Tanner PT, MPT, CMPT, ATC, CSCS

If you are experiencing pain, take action to eliminate it! We can help. Let us help you get back to the activities you enjoy. Call 804 320-2220 and setup an appointment today.

Filed Under: Physical Therapy, Spine Rehabilitation, Treatments Tagged With: Addressing Pain, Chronic Pain, Clarke Tanner, Clarke Tanner PT, Managing Pain, manual therapy, Optimal Solutions Physical Therapy, Pain Physiology, physical therapists, physical therapy, Richmond, Sports injuries, treatments, Virginia

Sports Medicine

Don’t let an injury keep you out of the game.

As an athlete, you demand a high level of function from your body. You want to remain pain-free and achieve optimal performance. At Optimal Solutions Physical Therapy (OSPT), our skilled therapists are also experienced athletes with the credentials and training to evaluate, identify and correct physical problems that cause pain and diminished performance. They can help you maximize your performance and prevent reinjury.

Treatment of injured athletes begins with a thorough assessment of biomechanics and movements, particularly those that are relevant to your sport. Our goal is to devise a treatment plan that restores strength, mobility and range of motion while correcting movement impairments. And just as every athlete is different, so too are the ways everyone experiences injuries. That’s why following a thorough evaluation, an evidence-based treatment plan is constructed and tailored to each athlete.
We use a wide variety of treatment techniques to help you get back to your sport. Our therapists are trained to provide manual therapy aimed at restoring optimal movement patterns necessary for remaining healthy in your sport. Studies have shown this to be more effective at returning patients/athletes to their active lifestyles more quickly.

If you are looking to recover from an injury or enhance your performance, we can show you how. Runners, cyclists, triathletes, swimmers, gymnasts and others have successfully returned to their sports after completing rehabilitation and performance enhancement training at OSPT.

Come see how OSPT can help get you achieve peak performance. Call us today at 804-320-2220 for more information or to schedule an appointment. You can also use our online Request an Appointment form.

Filed Under: Manual Therapy, Physical Therapy, Sports Medicine, Sports Performance Tagged With: Clarke Tanner, Clarke Tanner PT, manual therapy, Optimal Solutions Physical Therapy, OSPT, physical therapy, PT, Richmond, Sports injuries, Tara Cattaneo, Tara Cattaneo PT, VA, Virginia

About Thrive PTVA

We are a specialized manually based orthopedic, spine, and sports physical therapy practice that provides individualized care to its patients.

All of our therapists have specialty training, advanced certifications in orthopedic manual therapy, and extensive post graduate course work, and are highly qualified to help you reach your therapy goals.

Our methods include hands-on corrective treatment, movement training, dry needling, and therapeutic exercise provided exclusively by your therapist. Our objective is to teach you how to move efficiently and painlessly and to educate you on how to stay healthy.

We can help you achieve your goals to lead a healthy, active life–in a word, THRIVE!

THRIVE PT is a specialized manually based orthopedic, spine, and sports physical therapy practice that provides individualized care to its patients. All of our therapists have specialty training, advanced certifications in orthopedic manual therapy, and extensive post graduate course work, and are highly qualified to help you reach your therapy goals. Our methods include hands-on corrective treatment, movement training, dry needling, and therapeutic exercise provided exclusively by your therapist. Our objective is to teach you how to move efficiently and painlessly and to educate you on how to stay healthy. We can help you achieve your goals to lead a healthy, active life--in a word, THRIVE!

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