Ben Cormack
@CorKinetic
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GST MSK (sports therapy), I do a bit of teaching, a bit of writing & a bit of treating!
London
Joined July 2010
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Non specific lower back pain (NSLBP) is the most common MSK problem world-wide.
It is also an often-misunderstood problem!
This 🧵 will help to de mystify what NSLBP is & is not & hopefully provide positive information to pass on to those suffering with NSLBP
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Back pain is a big problem. Especially when in the very painful acute stages.
‘Movement snacks’ can really help to keep the body moving, reduce stiffness & hopefully reduce pain!
Here are 5 to try!
1️⃣Knee pivots
Keep intensity low & ROM within comfortable limits!
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What's the BEST exercise for BACK PAIN?
Well it seems everyone has an opinion, but what does the evidence actually say?
Let's take a dive into the data!
Here is a thread 🧵
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Rehab is a lot of guided trial & error
And that’s OK
That needs to be normalised rather than pretending to have all the answers
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One of the best prognostic factors for LBP appears to be the level of self efficacy someone has.
How often do people come away from a therapist with a list of things NOT to do rather than things TO do.
This has to stop.
Foster independence not dependence.
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Here are 20 common sense tips that I give to people regarding movement and exercise.
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Herniated discs can & do change with time!
This is an important message for some people with back pain.
"The probability of spontaneous regression of lumbar herniated disc: a systematic review"
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How does movement & exercise actually help pain? As it turns out there are a whole bunch of potential reasons why!
It's probably not the reasons many might think!
Let's take a dive into them, follow the the 🧵 for SCIENCE!
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Exercise checklist.
1. Did you explain the importance of the exercise for the problem?
2. Did you go through the program with them?
3. Did you provide a resource to refer back to?
4. Did you give regression/progression options?
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Lower back pain is the most prevalent & often challenging MSK condition out there
Here are some key texts in a 🧵 to help understand it better!
Let's start with this overview!
"What low back pain is and why we need to pay attention"
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What drives your exercise selection? The desired outcome should affect the reasoning!
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Any evidence behind this exercise thing?? Yes now you mention it 😀
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It’s strange that a painful massage, foam roll or treatment seems to be OK for many, even expected.
But a painful exercise is not advised & means damage
Makes little sense to me 🙃
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Getting a scan for 90% of back pain is like taking antibiotics every time you have a cold
It just doesn’t provide much benefit
That needs to be the societal message
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"Moving differently in pain: A new theory to explain the adaptation to pain"
Still the best paper on how pain affects movement
This is absolutely why many deficits that are seen clinically maybe more EFFECT than CAUSE of pain!
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I am going to be controversial!
Behaviour change principles around health behaviours are more important than specific exercise principles & programming for MSK problems
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If you are an exercise and movement PROMOTER (and we all should be : ) then you realise the importance of SELF EFFICACY.
It can literally make or break your treatment success.
But how do we improve it........
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Pain & it’s theories have been debated since the Greeks & Romans
Here is a short 🧵 on some pain theories that have shaped our modern perspectives on pain
Let’s start with the Descartes & the cartesian perspective of pain back in the 1600’s
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Advice & education are seen as first line treatments for back pain especially non specific LBP. BUT what advice & education should actually be given?
Here is a little tweetorial on what could be important stuff to tell your patient!
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Here is a really simple analogy I use to help people understand the pain EXPERIENCE
The idea of pain like a Russian or matryoshka doll
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Patient with LBP yesterday "I was told to stop running"
Me - "does running hurt?"
P - "no, it makes me feel good"
This is not the first of these conversations I have had (no shit) & this kind of flippant advice does much more harm than good IMO
Please stop!
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Exercise dosing for pain is not the same as exercise dosing for fitness
Maybe we cannot just take exercise concepts from the world of fitness over to the world of rehab.
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How many non specific painful problems in the body probably do pretty well with:
1 - Check for red flags
2 - Education that its likely not anything serious/damaged
3 - Keeping active with normal activities
4 - Basic self pain monitoring advice
I would venture a lot
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A common phrase I hear in rehab is “individualising” exercise programs
It is often believed that this means the sets & reps or the specifics of a program
Maybe, it should relate more to the PERSON….But how?
Follow this 🧵 to learn more
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Tendinopathy & all MSK issues are much more than local tissue & exercise 🤔
Occurrence of tendon pathologies in metabolic disorders
🏥Diabetes
🏥⬆️ adiposity
🏥⬆️ blood pressure
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Stress is a very complex subject - What do we know about stresses effect on pain? Here are some papers I have found useful.
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NEW BLOG - Pain education - How much neuroscience do you really need?
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The more data I see around exercise the more I believe the donut is more important than the hole 😂
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Download this FREE patient focused booklet about helping people live well with pain.
This is not about pain. But living better with it. It has some great insights from Joletta Belton. Pete Moore. Keith Meldrum & Amy Eicher.
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The obsession with perfect ‘form’ needs to stop with exercise
Exercise is not dangerous
It will not hurt you if you come out of ‘alignment’
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This blog seems topical!
Wrote this waaay back in 2015 on anterior pelvic tilt & why it's not that much of a big deal, actually my most read post EVER
Amazing to see this still debated!
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"From protection to non-protection".
Great paper from
@KWernliPhysio
Really important to understand the journey people go through not just an outcome measure. But also how these two things may be similar or differ!
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Enjoyment in physical activity is overrated
Humans do things because they value the benefits
"In fact, only 8% of runners said they ran because they loved running. 50% said they hate it, or merely tolerate it - Strava named this the ‘runner’s paradox’"
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Common sense guidelines for movement & exercise!
Fully downloadable and in multiple languages
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Playing around with some graphics over the weekend to use
Channeling my inner Pincus 😊
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The biggest issue with rehab programs IMO is that they often don’t fit into people’s lives
Simple, practical things for the win
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Why is there the belief that spines wear away with flexing but elbows do not?
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Here is what I would like anyone who has, is or might deal with BACK PAIN to know. Not fancy smancy but good basic information.
This is not finished! I would love any contributions from clinicians AND patients for good information that is 'NEED TO KNOW'
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Here is a little ‘movement snack’ I give to people with lower back issues.
3 big knee bends, 3 mid & 3 minimal knee bends x 2/3.
The aim is to feel looser and not to think about form.
Sometimes we need a little regular lubrication.
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Emerging Relationships between Exercise, Sensory Nerves, and Neuropathic Pain
Lots of interesting effects from exercise discussed!
Just need to make sure that the dosage right, as IME neuropathic issues can be easy to upset & hard to calm down!
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I’ve said this before.
Let’s see a “movement specialist” as someone who gets people confident in moving rather than diagnosing movement ‘problems’
These movement ‘problems’ seem to lack empirical data so far
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Nice slide from
@Tash_Stanton
“Early MRI without indication has a strong iatrogenic effect in acute LBP, regardless of radiculopathy status”
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BioPsychoSocial S & C!
Rehab can often focus on "whats the best exercise for...." rather than identifying specific outcome & then reverse engineering the process to create it
Here are a bunch of potential mediators that might require different programming to achieve
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This is all wrong
First you need foundational strength through a structured resistance program
Then optimal ROM
Finally learn the right motor control to activate the specific muscles
So dumb
This is Peggy. 95 yo next Friday.
1-year ago she fell. No injuries. But had a 6-hour long-lie.
She couldn't get up with her husband's assistance...even pulling up on a chair.
Physios: Teach your clients how to get up off the ground.
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Psychosocial factors are not here to REPLACE biological/physical factors.
They INCREASE our understanding of the people we are working with who are more than just their structures.
It is not a BINARY scenario. We don’t have to choose between them but be aware of whole picture
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REHAB EXERCISE PRESCRIPTION
Firstly exercise prescription is a lot messier than we like to admit & only gets more so in the presence of pain
We often need to realise that the 'prescription' is just the start of a process for the individual we are applying it to
1/thread
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One of the areas that I have changed my mind recently is the idea that exercise has to be fun.
Many runners don’t enjoy running but still do it
Moving has to provide something we value & its our job to help discover that.
This could tie into our goals or values
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Exercise dosing for pain is not the same as exercise dosing for fitness.
Do we need a new rehab model?
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Clinicians don’t treat…..
❌Pain
❌Pathology
❌Biomechanics
❌Tissues
❌Mechanisms
❌Averages
✅They treat people! 🧍♀️🧍♀️🧍♀️
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Back with the snacks!! 🥨🥨🥨🥨
Here are some more ideas to help move away from just those damn Theraband exercises 🤣
Remember, different snacks can provide different stimulus 🤯 & this can help to change outcomes
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Exercise can be used in many ways in rehab.
The most powerful tool is the clinical reasoning behind why you are doing what you are doing and the outcome you are trying to achieve.
This may even be different between two patients with the same problem.
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I see three main components to treatment:
1. Basic advice and information (inc explanation and timeline). Overcoming negative beliefs that limit.
2. Goal setting and graded return to cherished activities and movement in general.
3. Specific exercises/movements for the problem
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Watching the winter paraolympics this morning.
If you believe than any slight misalignment of the body simply leads to pain then this is a great example of the robustness we humans possess.
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Saturday confession
I very rarely give out a structured exercise program for LBP, like we see laid out in RCTs
Mostly a few exercises that fit in with life & a graded approach to valued activities 🤷♂️
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The exercise iceberg.
What really makes exercise programs effective is....doing them.
This has mostly to do with the bottom of the iceberg rather than the thing you see at the top (or in the gym 😀)
Inspired by the diet iceberg
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Being able to clinically reason, teach and motivate people to exercise is as much as a skill as any other part of MSK care
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If we look at exercise from a wider perspective then there are many parts we can interact with to help get it done!
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Tendinopathy is often seen as a degenerative issue that doesn't involve inflammatory processes & sparks controversy
However, there seem to be a bunch of different processes occurring
"Inflammatory mechanisms in tendinopathy – towards translation"
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We are often taught clinical practice is like walking the tightrope. A fine line between right and wrong.
In reality it is much more like a 6 lane highway. We need to be going in the right direction but a massive amount of room for variation and ways to do things.
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We may need to start working more ‘outside-in’ from the patients lived experience back to the biomedical stuff in many cases.
There are many great clinicians doing this already.
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Do people with lower back pain move differently to people without back pain?
Well it turns out they do!
Check this 🧵to see the data & also if we need to change movement to help back pain.....
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This is a cracking RCT!
Challenged my bias around interventions
Education (below) was as good as exercise!
"Does the addition of motor control or strengthening exercises to education result in better outcomes for rotator cuff-related shoulder pain?"
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Maybe nociception is about avoiding pain 😮?
"we conclude that acute pain is not a warning signal but rather is the failure of the machinery (nociceptor activity) designed to avoid pain"
Baliki & Apkarian 2015
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Strength exercise is good
Cardio exercise is good
Movement is good
Sport is good
Activity is good
So many ways to be more ACTIVE & we should promote them ALL
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🔥Fascinating tendinopathy paper here🔥
Increased tendon loads had an effect on tendon STRUCTURE!
This did not translate to FUNCTION or PAIN
No diff between passive, ecc or HL treatment 😳
Time, again, was strongest variable 🤔
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Such a brilliant paper!
Do flare ups reflect an actual increase in pain intensity? Or altered ability to cope with pain?
Changes the way that psychosocial factors & pain might be viewed 👍
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Unpopular opinion!
You don’t need to be super skilled at exercise prescription to help using exercise
You don’t need to be super skilled at manual therapy to help using manual therapy
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A neuroscience approach to pain has never been adequate to explain people's experiences
I asked this quite a few years back
How much neuroscience do you really need?
Not much IMO
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Exercise for pain is not the same as exercise for fitness!
Exercises can biomechanically incorrect but help symptoms
Exercises can biomechanically “correct” but make symptoms worse
Fit exercises to patients not the other way around
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Exercise thought experiment 🤯
I am much more into mediators & mechanisms in rehab than “what’s the best exercise for….”
Can we take the SAME exercise & target it in different ways by changing the context? I think so....
Here is a 🧵 expanding on this 🏋️♀️
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"From this analysis, BMI is an important predictor of spinal stenosis and disc herniation"
LDH is not just about lifting it seems 😳😬
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If you EVER treat LBP then you HAVE TO read the recent Lancet series.
Not SHOULD DO. HAVE TO.
(Yes I am shouting)
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LOVE LOVE LOVE this paper. A must read. Pain as metaphor: metaphor and medicine OPEN ACCESS
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Pain science and manual therapy seem to have become two oppositional camps.
Does manual therapy not require pain science to explain its effects on pain?
Anything that is done to help pain is pain science.
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One of the things I have learned from working with people in pain is that ONLY focusing on pain can lead to frustration.
Perhaps increasing things that are valued & cherished maybe another way to reduce the impact of pain & perhaps even pain itself
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One of my favourite papers from last year. "Towards a science and practice of resilience in the face of pain"
Less focus on risk factor & problems and more on moving forward and positives.
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It maybe worth considering that when someone tells you they have 10 out of 10 pain it is NOT the intensity of their pain they are telling you about.
It could be that it is the impact of pain on their function/existence. 1/
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What makes a good back pain consultation?
✅ Patients perception of being taken seriously
✅ Understandable explanation of the pain & diagnosis
✅ Reassurance & favourable prognosis
✅ Patient centred communication
✅ What can be done to help
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One of my favourite LBP papers from the last few years!
Quite a nice graphic to show that it's not just a tissue, or a joint out of place etc
Also "pain experience", nice touch 😀👏
@JanHartvigsen
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FREE pain resource to download. Pain, stress, peripheral & central sensitisation & descending inhibition.
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The exercise donut is back! Remastered for 2023 😮
Is there too much discussion about the donut hole (exercise specificity) and not enough about the donut whole (all the other shizzle) that maybe really matters!?
Lets focus on the WHOLE!
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Lower back pain is often blamed on a lack of physical capacity. Time to rethink?
Decreased physical activity?
Even with fear avoidance?
Strength?
De-conditioning?
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Do we focus too much on illness & not enough on wellness?
Not new concept but an important one. We don't have to change negatives but build positives!
“Attempts to control a chronic stressor are often counterproductive & can magnify negative effects of the stressor”
Sturgeon
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Do patients NEED to have their PAIN EXPLAINED? In this study advice and education was enough in acute pain episodes. Pain education provided NO more benefit.
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BioPsychoSocial S & C!
Rehab can often focus on "whats the best exercise for...." rather than identifying specific outcome & reverse engineering the process to create it
Here are a bunch of potential mediators that might require different programming to achieve
1/
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Helping people to exercise is not giving them an exercise.
It is overcoming barriers, mindset & motivation and tapping into a why.
But above all it is planning and routine.
Be the coach.
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Exercise & movement like all interventions can be over complicated
Sometimes it pays to be simple!
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In what location do people get back pain?
"The most common area of LBP was in the immediate paraspinal area with 130 (75.6%) participants with point prevalence LBP"
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“Make things simple but no simpler” Einstein
Sometimes the exercise can be simple, but the person in front is complex 😀
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My stock answer to pain/injury questions from friends & family is always:
“Give it a couple of days” 😂
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