This week, Michael is joined by osteopath Josh Blencowe from MD Health to discuss back pain – one of the biggest factors preventing us from living a full and happy life.
In this episode, Josh and Michael review the common causes of back pain, including the indirect causes of back pain that have only recently come to light due to recent progresses in pain science. They also explore the role fear plays in our experience of pain.
Most importantly, they list the preventions and treatments you can use to overcome back pain so you can get back to the things you love.
Let’s get confident!
CLICK HERE to read the full transcript from episode 21 of The Confident Body Show
Topics discussed in this episode:
- What causes lower back pain?
- The most common types of lower back injuries
- The role fear plays in our experience of pain
- The indirect causes of back pain (that have only recently come to light)
- How to overcome back pain so you can get back to the things you love
- Lower back injuries are common and can be due to either a particular incident, but most likely have occurred due to accumulated load on the back over time. (2:30)
- Although the most common injuries in the lower back are either disc-related back pain or facet joint pain, lack of strength around the lumbar spine, the hips and pelvis are a major contributing factor. In particular, the fear of movement plays a massive part in how you perceive pain and how much it affects your life. (4:00)
- Pain science has come a long way in the last few years and the effect of stress, lack of sleep, lack of good nutrition have direct effects of the “feeling” of pain and how it affects your life. In particular, there factors raise your levels of cortisol, which amplifies pain. Doing the thinks that you love and reducing the “fear” of pain is part of the journey of managing back pain. (11:30)
- Treatment that aims to “fix“ back pain never works in the long term, because the strength and contributing factors are not addressed. Working on your strength, ability to manage pain and movement awareness are key and go hand in hand together with “hands-on” treatment for long-term changes and getting the life you deserve. (25:00)
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Click on the Dash icon below to see the entire show transcript
Episode 21: Full Transcript
Welcome to The Confident Body, where experienced health professionals discuss how to get the most out of your body for the lifestyle you choose. We believe everyone can exercise and get the most out of life, regardless of your injuries or health issues. Now, here’s your host, senior physiotherapist, Michael Dermansky.
Michael Dermansky (00:23):
Hi everyone, and welcome to the show that helps you become more confident in your body so you can keep doing the things that you love. My name is Michael Dermansky, I’m one of the senior physiotherapists here at MD Health, and today I’ve got another special guest and a return guest to the show. Josh, who’s one of our osteopaths at MD Health in Carlton. Welcome to the show again, Josh.
Josh Blenclowe (00:41):
Thank you Michael. Thanks for having me again.
Michael Dermansky (00:44):
Great. And today we’re talking about topics that we actually started probably last time you spoke, and we’re going into a bit more detail about it too, and that is, is your sore back stopping you from doing the things that you love? And you were sort of starting to talk about a few stories, but I want to go into what bit more depth. So I guess to start off today, what’s the usual story that you hear from clients who come in due to back pain? That’s a very broad term.
Josh Blenclowe (01:12):
Yeah. Back pain to me is the whole spinal column, but generically speaking it would be more in terms of the lower back. So a lot of the scenarios that I’ll talk about today will most likely be involved with the lower back. So yeah, a lot of different scenarios come into play that present to us. Obviously pain being the number one thing that would normally bring people in. Several different scenarios, like difficulty bending forward or picking things up the floor, difficulty engaging in simple daily activities like their walking or running, their working jobs, gym or fitness, any sports hobbies or being a mother or father to their child. Having the inability to do the things that they love with friends, family and colleagues, yeah.
Michael Dermansky (02:14):
When you hear a story, they usually tell you, oh, I picked this up and I hurt my back. Or is it more of a, I don’t know how this happened, this has happened over a period of time, but nothing in particular. What are the kind of stories you usually hear when they come in the door?
Josh Blenclowe (02:31):
It can really depend on if it’s a first time basis or something that’s a bit more chronic. So yes, injuries can happen and trauma can happen. So for example, an unfortunate car accident would be very sporadic and can basically not be harmed. And yeah, we see a lot of people coming in with probably a buildup of tension over time, repetitive movements in their daily work. So for example, they might be a tradie who’s on the tools, lifting heavy objects and doing repetitive labor, day in and day out, who haven’t had the exposure to exercise or rehab in the past.
So they’re a few clients that come in that are quite sore in that regard. Things like you might have twisted the wrong way under a certain amount of load causing a really nasty flare up within the lower back and back pain itself. So yeah, there’s a numerous amount of scenarios from clients that come in, which can be something quite simple and unfortunate that’s happened or something that’s been going on for quite a long time.
Michael Dermansky (03:55):
Okay. So what are the kind of findings in terms of injuries and the contributing factors you tend to find?
Josh Blenclowe (04:04):
Once again, this is dependent on a number of things. So depending on the age of the patient, any sort of previous history or experiences with back pain in the past, what are their daily movement patterns like, any sort of work related behaviors, these can all contribute to several common findings. So in the main, I guess findings or conditions that we will see with clients coming with back pain will be those disc related clients, whether it be a herniation, a protrusion, a prolapse, or just general loss of disc height. You can see some vertebral end plate fractures, which is usually the first stage before any sort of disc related injury can occur.
We also see facet joint sprain, so those facet joints enable the spine to basically move. So some of those joints and segments can get quite irritated and sprain. We see a lot of osteoarthritis coming through in the lower back, which obviously creates a lot of stiffness in the joints and potential stress structures as well, from a lot of repetitive high loads, especially seen in sports and stuff like that.
So a lot of the symptoms that go along with that will be stiffness, obviously pain is a massive one and inflammation, with or without potential neurological symptoms. So that referral in the area or down the leg depending on the segment affected in the lower back. So they’ll get that tingling, that numbness, even loss of motor control or muscular control, which can cause weakness, deactivation of the muscles of the leg, which the lower back will control within the nervous system.
And basically taking that into account, the findings that we will see, which a majority of the case, will be a lot of pelvic instability, a lot of muscular imbalance and weakness, poor movement patterns and control and then having also that non-conscious mind body connection with posture and negative thought beliefs as well.
Michael Dermansky (06:42):
Right. So it’s interesting what scenarios can cause the issues, but also the contributing factors that you said, that pelvic control and stability, the poor moving patterns and the negative mindset in terms of posture as well, that also being the way you think about it and the way you manage back issues is just as important as the actual physical issues as well.
Josh Blenclowe (07:09):
Michael Dermansky (07:11):
So I guess in that same direction as well, could these injuries have been prevented?
Josh Blenclowe (07:18):
Look, the majority of the time, yes. As I’ve said before with something like direct trauma, like a car accident, obviously no amount of rehabilitation or prevention can help with that. But if we look at more of the biomechanical repetitive movement side of things, then 100% yes. So they can be prevented with a positive, confident and stable body. So the things I mentioned before about that pelvic instability, that weakness and basically that lack of mind muscle connection with their daily movement patterns can be changed and can be rehabilitated.
So a conscious mindset on posture, lifting technique, and engaging in positive movement patterns can prevent the injuries from occurring or getting worse, which is where we can see a lot of patients go from being in an acute back pain state to unfortunately a chronic back pain state.
Michael Dermansky (08:30):
Right, excellent. But it’s interesting you said that a lot of it can be prevented as well. Someone could have had a direct trauma, you can’t do anything about that too. But the long term ones as well, that you can have a big impact on those as well. You can work on your strength, you can work on your control, you can work on your conscious moving patterns as well and the way you believe about lower back problems as well, that’s all manageable. And as you said, they can go from acute, so a new back injury to something that’s been there for a period of time. But that can be managed, it’s not, you are stuck with this problem the way it is all the time. This will be different over time if you do something about it.
Josh Blenclowe (09:06):
Yeah, that’s right.
Michael Dermansky (09:08):
So what do you find’s stopping people getting back to their normal life or even better than that, to the life they really want, who have got back pain when they come in the door?
Josh Blenclowe (09:19):
Well, the number one thing is obviously pain and we just need to reiterate that the pain is completely normal. We all will experience pain and pain is our protective mechanism against harm harmful stimulus. So that’s a major thing. We’ll get into pain in the next question. However, fear as well is massive. So that negative mindset. Quotations like I’m damaged, I’m broken, I don’t think this can be fixed. I’ve had multiple different approaches in the past that haven’t worked, why is this going to be different, et cetera.
And with the fear a lot will come in with a heightened state of anxiety, understandably, and they’ll freeze up. So they think if I move, I’m going to make this worse, which as we know, movement and exercise and activity is the best thing for that condition. However, being in that heightened sympathetic response, that flight or fight basically, is going to put them in that state where they’ll naturally kind of freeze up and can make things worse. So yeah, immobility as well, just general stiffness and the potential inability ability to move the way the that they normally would doing the things that they love. Yeah.
Michael Dermansky (10:56):
Well it’s interesting is you said that the fear behavior is a big aspect of people not being able to do it, because these things will heal. I mean just because you’ve had a disc [inaudible 00:11:06] doesn’t mean you’re going to have one forever and doesn’t mean that at the start and later is the same thing, but often, I can’t do this because I’m going to hurt myself. Well, maybe at the start you did, but this is no longer the case. That was a while ago. And you can start to do some of these things as well. As as your body’s strength and ability’s able to match what you are requiring it to do. But it’s not a fixed for life problem. You don’t have a back issue, that’s it, I’ve got a bad back, I’ve got a bad back for life. It’s not often the case.
I guess that goes into the next question as well, that there’s been a lot of research and discussion about pain science and how it’s related to getting back to people doing things they love. We began talking about that, now what does that mean to you? Where’s this big pain science thing coming into it too?
Josh Blenclowe (11:55):
So yeah, pain science is extremely complex. And I think from a clinician perspective, if we can give that patient a very general understanding of pain and the reason that they have the pain, is crucial. So pain isn’t always isolated to the tissue damage itself. There’s a lot of other external factors that come into play that can influence or heighten the pain that they’re in. I like to explain this with the water bucket analogy. So imagine that your capacity to carry tension is a bucket and the water is the tension filling up that bucket. That bucket is pretty much always carrying some water. Water is being put in and taken out at different rates depending on the day and activity.
Sometimes the water overflows the bucket and when it does, that’s when you feel the pain. As soon as you’ve done something to reduce that water enough so it’s no longer overflowing, the pain will usually stop, even if it’s only for a little bit. People have varying size of buckets. With a big bucket, muscles get to virtual concrete before they notice any discomfort. This is the client who comes to me with a little bit of lower back pain and I’m wondering how they’re able to move. Other people have very small buckets. This is the client who come in with excruciating pain, unable to turn his or her neck or move their lower back in this case. And all I can find is one single knot at the top of the shoulder or within the lower back, with very little other tension. This by the way, is extremely rare. Most people have larger versus smaller buckets.
When your bucket is near full, it only takes a small aggravator or a little extra stress at work and extra mile in your run to create a serious problem. So how you fill up your bucket, so on a day-to-day basis, you’re likely net positive, i.e. you’re putting more water in than you are taking out. Repetitive movements create tension, running, walking, typing, working under load, et cetera. Long hold muscle contractions also creates tension. Sitting with your head forward forces your neck and shoulders to contract to hold up your head, the weight of your head or lifting a shoulder that has a bag on it. Small imbalances are like putting water in the bucket with a teaspoon or a dropper, think a very slightly forward head position or a minor deficit in glute activation. So big imbalances are like putting water in the bucket with a large cup or a jug. So think horrific mechanics when running.
So why you don’t feel the bucket as it’s filling up, so muscle changes very slowly over time. As you add a little tension, your body adjusts, finds a way to work around it and you don’t feel the tension at first. In one way this is helpful, you wouldn’t want it want to be debilitated every time you’ve got a little extra muscle tension. What’s not so helpful is this means you’re slowly building up tension over time without noticing. That one day you do one extra activity or movement that tips it all over the edge and your neck goes into spasm, your calf muscle tears or you realize you can’t lift your arm over your head.
So taking or keeping water out of the bucket, this is where taking water out of the bucket comes into play. Believe it or not, you’re already naturally taking at least some water out of the bucket every day. Any movement will at least minimally release some muscle tension by warming up the muscle or stretching it slightly. If you find a specific ache or pain gets worse when you stop going to the gym to train regularly, that’s because the heat and movement of your workouts, were taking a little water out of the bucket each time.
Michael Dermansky (15:54):
Josh Blenclowe (15:56):
Massage that actually reduces muscle tension, takes water out of the bucket versus a general and/or superficial relaxing massage that doesn’t change underlying muscle tension.
Michael Dermansky (16:08):
Josh Blenclowe (16:08):
Yean, so I think that really puts into perspective that pain can fluctuate a lot and as I’ve just outlined above that many external factors can influence that pain. So a lot of stress in your life or job will naturally change your psychological state. Increased cortisol levels have a negative impact on pain, poor sleep as well can have a large influence on tissue repair and recovery and tissue healing and decreased cognitive function, poor diet and nutrition, which is what we need for fuel and energy can have a large impact on pain levels. And rehabilitation and posture and those daily repetitive body positioning movements as well can have a large influence on pain.
Michael Dermansky (17:07):
So it’s interesting what you say about how pain science comes into it too and I mean, if you look at the influences on how you feel pain, as you said, pain is the harm or potential harm, is your body’s protecting mechanism to. So there’s two major things. I mean these are very simplified chemicals, but as you go into levels of stress, your cortisol levels rise. It’s a naturally occurring hormone as well, but it also exacerbates, adds fire to the flame and makes it more present.
So pain isn’t felt directly in the area. It goes through a bunch of relay stations that it gets from the brain and it’s modulated 90%. So 90% of what you feel is modulated through different relay stations than how you feel it. And so when you have things that stress you out, it just heightens your response to it. It doesn’t mean you don’t need more damage, but your response to it is heightened because of the normal chemical release.
Now vice versa, when you do things you enjoy, you do exercise, when you do things you enjoy that release endorphins, you release serotonin, all these other chemicals as well that dampens your response. So again, the injury hasn’t changed, but your body’s reaction to it has. And the other things that you said, having enough sleep, that has a direct effect on your cortisol levels. So if you don’t have enough sleep, your cortisol levels rise and that heightens pain, plus you’re tired and so it affects the way you feel. As you said, diet makes a big difference, your ability to recover. So having enough carbohydrates, got to have proteins, it all makes a difference. Your ability to recover as well.
So it’s not just the injury or if I don’t do this, I won’t get hurt. As you said, there’s a bucket, that bucket doesn’t change, just ’cause you’ve done a little bit more doesn’t mean you hurt yourself more, it just means you’ve done more than what you’re capable of doing at the time. And then your body has to go back and go back to a level it can manage. So you can make yourself stronger, you can affect what happens in your life, your stress levels as well. You can affect your sleep, biggest factor on stress levels and recovery. You can affect your diet. A lot of major parts that are outside of the injury that have a major effect on the way it feels.
Josh Blenclowe (19:27):
Michael Dermansky (19:31):
So I guess the next couple of things is again, it goes along those lines. If someone has a flare up in their belt, lower back pain, which you and I see all the time, does it mean there’s something wrong with their rehabilitation process, has something gone wrong or do they need to take a different approach which throw everything out the window?
Josh Blenclowe (19:53):
Well, rehabilitation and lower back pain is not linear. So depending on the stage of where the client is, whether it’s that acute or chronic stage will have a very dependable line of rehabilitation. So flare-ups are completely normal and common. They’re going to occur because if we are strengthening a certain area, as I said before, when muscles get tight, they hold a lot of tension. So potentially that tension within that can fill that water up in that bucket and create a bit of a flare-up, increase in pain, et cetera. And as there are many external factors contributing to pain and their injuries, several factors can therefore impact the occurrence of a flare-up.
So yes, they’re completely normal and as I mentioned in the last podcast as well, that we do address those flareups. We do address anything new that comes on the scene with another assessment and we can change the direction of our rehabilitation approach. It’s very, very flexible and tissue healing time is variable and if multiple different structures are involved, the length of recovery will be greater showing a non-linear pathway. So this does not mean they have not taken the right approach. It’s about creating a more conscious mind and body connection to engage in the reduction of poor movement patterns and lifestyle posture choices and positioning.
Michael Dermansky (21:38):
I see. So it’s interesting, there’s a couple of different factors here as well. It’s like when you go through rehabilitation process, you are challenging that body to get stronger and you’re going to be on the line, you’re going to be on that edge of working a little bit more than what your body is able to do to be able to get more capacity, to get that bigger bucket. And so sometimes you’re going to go over the edge a bit and that’s okay.
It doesn’t mean that everything’s going out the window, you just need to back it off, but continue to push the line. Because if you’re not challenging yourself to some degree, there’s not going to be a change. It’s going to be the same pattern again and again and again. Plus on top of that too, when you feel better, you start to do more things.
Josh Blenclowe (22:20):
Michael Dermansky (22:20):
And so sometimes we see people that everything’s going right, but they do things outside of the clinic as well, that’s going to be more than the body can handle. And that’s just them reminding, saying, it’s great that you want to do this, you’re just not ready for it yet.
Josh Blenclowe (22:37):
Michael Dermansky (22:37):
And I guess the last part of that, as you said as well, sometimes things go wrong and that’s okay. So then it’s important to reassess, is this still the problem or is this something new to come about that we need to change direction? And all of that’s normal. Nothing ever goes straight down the line exactly as expected. That’s why you need to be flexible in your approach, this may work now but later it may not be the right thing to do because circumstances change.
Josh Blenclowe (23:03):
Correct. And I think that as everyone’s different, everyone has slightly different structures within the lower back. Obviously there’s differences within the pelvis with men and women. So therefore the exercises cannot be the same and the approach cannot be the exact same for that individual. So for example, I explained this to a client not long ago who has a very small disc protrusion, and the water in her bucket I would say is quite high. So she’s quite anxious about the situation and whenever she moves and she’s in the studio and we are doing all those great things, she does feel better.
But then when she gets caught up at work, et cetera and can’t come in and she’s not as active, then she comes in, she goes, “Oh Josh, I’m not really feeling the greatest today. I’ve had a bit of a flare-up,” et cetera, that’s completely normal. So everyone’s completely different. So for example, I don’t like to go off scans too much. So she’s very conscious of the scan saying a small protrusion, which isn’t the best result. However, I explained to her that you are just symptomatic with that. If I had the exact same scan, I could even have a small disc protrusion and I don’t know about it.
Michael Dermansky (24:27):
Josh Blenclowe (24:28):
It’s just that conscious and non-conscious mindset as well and someone can be symptomatic or non-symptomatic. So yeah, it’s variable and we can treat that.
Michael Dermansky (24:39):
It’s interesting ’cause we see very similar scenarios with arthritis as well. ‘Cause we can have an x-ray result and there is severe, severe arthritis, there is bone on bone on bone, on bone on bone. There is no space and yet they can feel nothing at all. And yet we see people with very mild arthritis and they’ve got really severe symptoms as well. It really is dependent on the way the person, their body responds to that injury as well and it’s variable and you have to take that into account.
Josh Blenclowe (25:08):
Michael Dermansky (25:09):
So let’s go back to the last question today. What’s the difference in outcomes of people who take an active participation in rehabilitation and those rely on others to fix them? How do you see the difference?
Josh Blenclowe (25:21):
Yeah, so it’s chalk and cheese really. Combining the two is probably a gold standard. If we separate the two, so if we look at the rehabilitation side, obviously we’re strengthening those postural muscles, those muscles that are providing or influence a lot of pelvic instability and lower back instability, strengthening those will be the underlying cause and fix to a majority of their issues going on. Education for me is massive. So what we’ve talked about today with the whole pain science and all of that is extremely crucial, as a lot of individuals come in that they don’t know the reason why they have this pain.
So I think it’s really important to educate them as to why they’re receiving this pain, why other factors can influence that pain and to basically give them an understanding as to why they’re feeling this way. It gives them that reassurance basically, moving forward.
Michael Dermansky (26:33):
Josh Blenclowe (26:36):
Yeah, mindfulness in regards to their behaviors and movements is another rehabilitation aspect that we can work on. And then we look at the hands on side. So from my perspective with the osteopathic approach, which obviously increases alignment and we can reduce that muscular tension and for example with osteopathy, they might have a lower back dysfunction. We’re obviously going to look at the thoracic spine, which is above, and then the whole pelvis, the hip, et cetera. So it’s not just as simple as, that one segment is affected. The kinetic chain approach where we increase range of motion, reduce muscular a tension and basically fix them, if you will.
However, in my opinion, that for majority of the time, that actually doesn’t fix the issue. So it doesn’t address the underlying cause. Yes, they’re probably going to have weak glutes and poor hip mobility, which can therefore create a lot of stiffness in the lower back and dysfunction in the lower back. On top of their repetitively daily movements for example, a desk worker sitting too much or a tradie bending over, shoveling dirt, et cetera, it’s only going to fix the issue, like a bandaid approach I like to call it.
Whereas the rehab will address the underlying cause and fix it in the way that it should be fixed. But if you combine the two, for example, flare-ups are completely normal and common, that’s where hands-on can be really effective in reducing that tension, decreasing pain, increasing comfortability and increasing mobility too, to therefore get the best out of their strengthening in the rehabilitation work.
Michael Dermansky (28:34):
Yeah, it’s interesting, as you said, both have a place, so the hands-on treatment as well has a place, to manage muscle spasm, to reduce short-term pain, so you can actually do the rehabilitation side, but unless you’re doing the strengthening side, unless you’re understanding pain science, unless you’re doing to change things at what work, it’ll just repeat itself. It will just keep it happening again and again and again and again, because we can’t make you stronger. We can’t magically put strength into your muscles or your pelvic control or so forth with our hands. We can help you with positions that reduce muscle spasm, but there’s nothing we can do to magically impart strength in an area. You have to do the work.
Josh Blenclowe (29:16):
Correct. Exactly. Yeah.
Michael Dermansky (29:19):
Anything else you want to finish off with today, Josh?
Josh Blenclowe (29:22):
No, I think that sums it all up. That’s quite information overload for the listeners. Yeah, look, whenever we’re talking about pain, as I said before, it’s very complex. So I think just giving the patients that understanding in a very general setting, with the water bucket theory, I hope that helps. And then just to realize that the hands-on approach is great, but it is just a band-aid fix.
We need a little bit of work from the patient itself to strengthen those areas and to basically go from a non-conscious state where their anxiety is quite high, to therefore getting them conscious of their body, getting them stronger to the point where they go back into that non-conscious state with a better, healthier body and hopefully they won’t have any issues in the future with that. Yeah.
Michael Dermansky (30:29):
And they end up having the life they want, which-
Josh Blenclowe (30:31):
Michael Dermansky (30:32):
They have a direct control over.
Josh Blenclowe (30:34):
Michael Dermansky (30:34):
So the time factor will vary, but they have a direct control over where their body ends up in the long term.
Josh Blenclowe (30:40):
Exactly. That’s right.
Michael Dermansky (30:42):
Well thank you very much for your time today, Josh. It was great information about lower back problems as well and what can actually be done. And you know, what’s stopping people getting back to doing the things they love. We want to see that. We want people to have the life that they want and they deserve, but it involves a two-way street. Us helping you guide you there, but also you doing something about it too and really making a conscious effort to make change.
Josh Blenclowe (31:10):
Michael Dermansky (31:12):
Thank you very much for your time. We’ll talk to you next time too, Josh. Thanks a lot.
Josh Blenclowe (31:15):
Thank you, Michael. Thanks
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