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How many times have you promoted exercise as homecare to your patients to try and improve their health? Well, now doctors are getting on board with exercise and mental health. Findings from the study reveal that physical exercise is so effective at alleviating patient symptoms that it could reduce patients’ time admitted to acute facilities and reliance on psychotropic medications.

“Exercise Is The New Primary Prescription For Those With Mental Health Problems” – Neuroscience News

Interesting, this study demonstrated a higher level of oxytocin release and a possible improvement in Autism Spectrum Disorders, but there is a catch. Read on to find out why.

“Foot Massage May Increase Oxytocin And Affect Brains Reward Regions, But There’s A Catch” – Nick Ng

Need to upgrade your research game, but afraid of getting swamped by all the articles that don’t help? Here are some tactics to help you avoid getting weighed down with the research you don’t need.

“9 Pubmed Ninja Skills” – Hilda Bastion

If you’re blogging for your massage business at all (which I hope you are) then you understand the struggle of writing science-based articles and making them easy to read. Well, here’s some great advice from Greg Nukols on how he manages to do it.

“Write Science-Based Content That People Will Actually Read” – Jerilyn Covert

We wear many hats as Massage Therapists, business owners, marketers, therapists, and coaches…yes coaches. Each time a person is on your table and you’re communicating with them, you’re also coaching them on movement, homecare, and psychosocial aspects of life! But what about when they don’t do the recommendations you’re giving them? Well, maybe it’s the coaching!?

“Why Won’t Clients Just Do What I Say?!?!” How To Fix Every Coach’s #1 Frustration.” – Julia Malacoff

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We’ve been talking lots about low back pain lately, however, most of the time when we see low back pain in a clinical setting it is referred to as “non-specific” low back pain.

This basically means there is no underlying cause or incident that can be attributed to the patient’s pain, yet they are still undergoing a painful experience.

Part of our clinical intake and decision making should be able to point us in the right direction when the pain isn’t non-specific, especially if the patient is experiencing one of the red flags of low back pain. Some of these can be difficult to differentiate as there is usually a little bit of overlap between symptoms and really narrowing it down can present its own challenges, especially if you’re trying to prevent a patient from catastrophizing about their pain.

One of these situations is a condition called “Ankylosing Spondylitis” and the symptoms have some overlap with other red flags, so it’s crucial we are able to differentiate between this and other conditions, if for no other reason than to refer out to the appropriate health care professional for the person to get the proper care.

Signs, Symptoms & History

Ankylosing Spondylitis is an inflammatory rheumatic disease that traditionally affects young people and usually becomes noticeable around 26 – 28 years old, with men being affected more than women by a 2:1 ratio and they may have more structural changes than women.

While it is generally recognized around 26, 80% of affected patients are diagnosed under the age of 30 and only 5% develop the condition above the age of 45 (some important things to take note of with your intake).

This condition falls under a group of spondyloarthritides, of which there are five different conditions:

  • Ankylosing Spondylitis.
  • Psoriatic Spondyloarthritis.
  • Reactive Spondyloarthritis.
  • Spondyloarthritis associated with inflammatory bowel disease.
  • Undifferentiated Spondyloarthritis.

Regardless of which subtype a person has the main thing that occurs is inflammatory back pain starting with sacroiliitis and inflammation occurring in other spots on the spine along with some peripheral arthritis (usually lower limb) and in rare cases, causes issues with organs.

Generally, the symptoms start with a dull pain deep in the gluts and/or low back accompanied by stiffness in the morning that lasts for a few hours. It improves with movement but comes back with rest. Within a few months, the pain becomes persistent, felt on both sides and gets worse at night. The spinal stiffness and loss of mobility come on as a result of inflammation and the resulting damage caused by the disease. Some of the damage is due to bone remodeling and bone loss because of the inflammation involved.

The cause of the disease is unknown, but one of the predisposing factors related to getting this is the gene HLA B27, (not that you’ll be able to know if your patient has this) in fact, 90-95% of those diagnosed with AS (ankylosing spondylitis) are positive for this gene with the risk of developing the disease around 5% in those positive for the gene and even higher for relatives of patients, however, most of the HLA B27 positive people remain healthy.

Now, I realize a lot of that just sounded like a bunch of sciencey talk (which it kind of was) but how does it all apply clinically?

Well, what we need to look out for is:

  • Low back pain and stiffness for longer than three months, which is relieved by exercise, but not with rest.
  • Restriction of lumbar ROM with flexion/extension as well as side-bending.
  • Restriction of chest expansion in comparison to others of the same age and sex (not 100% sure how you would measure this).
  • Sacroiliitis identified through imaging.

The use of MRI is what usually identifies the sacroiliitis because of its ability to see active inflammation along with structural damage to the bones and cartilage that can be seen, which hopefully catches the disease early. However, the MRI alone isn’t en0ugh for a diagnosis. It is better diagnosed if at least three clinical, laboratory (gene testing), or imaging results are positive. Clinically  we would look for:

  • Morning stiffness longer than 30 minutes.
  • Improvement in back pain with exercise, but not with rest.
  • Waking due to back pain during the second half of the night.
  • Alternating buttock pain.

This is where our understanding of the red flags of low back pain comes in to play. Low back pain greater than six weeks and for those older than 18 are red flags due to a tumor, infection, or a rheumatological disorder. If the person has no history of cancer, the tumor is quite unlikely, and if there is no reason to suspect an infection, well… that leaves us with rheumatological issues that we may need to refer the patient to a doctor for further diagnosis.

Exercise And Massage Treatment

Our goals for treatment should be to reduce symptoms, minimize spinal deformity, disability, and in reviewing research there is one topic that continually comes up as a non-pharmaceutical treatment for AS…exercise!

There are many similarities between rheumatoid arthritis (RA) and AS, but some similarities are still present, so, much of the research revolves around RA instead of AS. It is recommended for people to get 30 minutes of moderate intensity exercise per week (brisk walking is suggested) 3 days a week, or the equivalent of 90 minutes/week. However, this can include dynamic exercise to improve muscle strength and aerobic endurance.

RCT’s showed how exercise was most effective in physical function and spinal mobility for patients with AS, more specifically supervised exercise was even more effective, and pool exercises were more popular than land based.  One study showed that a combination of self and manual mobilization at home helped with chest expansion, posture, and spinal mobility. 

Another study on the effectiveness of group exercise was done with one group who was supervised and the other was given the exercises/movements as homecare. The results showed a positive influence on the duration of morning stiffness, chest expansion, and overall well being after intensive supervised exercise classes, however, the home exercise group didn’t really show much improvement. It is believed that part of the reason for this is the psychosocial factors that come with being around other patients with similar problems and the education given in the classes. I would venture to assume there is a certain amount of motivation that comes with being in a group to actually “do” the exercises as well (part of the reason I push myself at CrossFit a lot harder than I do in the gym alone). The combined group exercise has also been shown as a more cost-effective treatment compared to standard treatment alone (use of NSAIDs). 

So, what does this all mean for us as massage therapists? 

Well, a lot actually, and in a positive way. Quite often “complementary and alternative treatments” are recommended in conditions like this and well… we just happen to be one of those treatments. When we look at what’s recommended, there aren’t any clinically controlled trials (although here is a case study that looks positive) on our effectiveness, but massage is shown to be SAFE! However, it is recommended when looking at acupuncture and chiropractic manipulations under the same light to view them with caution, so SAFE is GOOD.

As we have discussed so many times on this blog we also have an opportunity (and a responsibility) to look at the biopsychosocial aspects of what could be affecting our patients with AS. Since this generally happens at a younger age when people are typically in their most productive stage of life, there is a general fear around work disability which can be a contributor to the persons pain. This is one aspect where educating on how exercise can help prevent progression of the disease can be a valuable tool during treatment. One of the other issues is a lack of energy and fear of joint damage around exercise, which gives us another opportunity.

When we look at many of the exercises used in the studies we mention, they used: stretching, mobilization and strengthening for the back, aerobic, along with postural and respiratory exercises. While exercise may not be in all of our scopes, we generally, can do stretching during treatment and can also do active and passive range of motion (which is essentially mobilization). Not only is this part of the recommended exercises, but it’s also an opportunity for us to reinforce that movement and exercise is safe and promote resilience in their dealing with the condition. If exercise is in your scope, use the opportunity to go for a walk with your patient (they may need your reassurance and support to do this), do some active movement, some repeated motions to increase mobility, and above all reassure them this is not only safe, but beneficial!

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We know that communication with patients is a crucial part of treatment, so the way we talk about pain is equally important. Helping a patient rephrase their pain and how they talk to themselves about it can be helpful in encouraging resilience and decreasing pain.

“The Right Words Matter When Talking About Pain” – Michael Vagg

Yet another example of how loading tissue can help injuries. This research shows how exercise has anti-inflammatory effects and helps prevent cartilage degradation in conditions associated with arthritis.

“Exercise Helps Prevent Cartilage Damage Caused By Arthritis” – Queen Mary University of London

Reddened skin, mechanical effects, pressure ulcers, venous insufficiency, and all other things related to circulation and massage. This outlines where evidence is and is not in favour of the idea that massage increases circulation.

“Does Massage Increase Circulation?” – Paul Ingraham

Quite often the value of a relaxation massage gets devalued as we look to prove what massage therapy can do. However, we should never doubt it’s value and this post gives us some quality assurances around the benefits of a great relaxation treatment.

“Massage Therapy For Stress And Anxiety” – RMTAO

When products get the label of “natural’ or “organic” we automatically assume it’s better for us. Well according to the NIH, this isn’t necessarily the case. While some of them may be good for us and some supplements may come from natural sources, it doesn’t always mean it’s safer or better for us.

“Natural Doesn’t Necessarily Mean Safer, Or Better” – NIH

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So your best needling/IASTM/soft tissue/manip improved cervical/scapular/shoulder ROM. What next? After manual therapy or a repeated loading strategy, pain and ROM is often rapidly improved. 

Repeated passive end range loading often keeps this improvement between visits. However, many times restoration of motion and improvement in pain thresholds does not always improve higher function or tissue resiliency to load.

When motion is realistically symmetrical and threat free in all planes, someone can move their shoulder and head/neck with varying rates of speed, I stabilize the area with eccentric isometric shoulder shrugs.

In this case, cervical/shoulder ROM was restored with light IASTM to the right cervical spine and right upper trap for a minute or so, followed by repeated cervical retraction and end range side bending to the right. Upon 2nd or 3rd follow up, with the above motions cleared and functional pre-post test still being threat free, I would progress to this “stabilization” phase of Eval, Reset, and Stabilize.


Cervical Spine and Shoulder Exercises - YouTube

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Our ultimate goal is to help our patients live life with less pain than before they came to see us. However, with each treatment, they may not realize whether they are getting better or not, it may take some questioning to figure it out. Here are some good things we can question our patients about their pain.

“Am I Feeling Better?” – Jon Cain

We know the importance of massage therapy and it’s help with mental health issues like anxiety, stress, fatigue, and depression. Well, now there’s been some research done to show how it can help with a very stressful profession…nursing. While more research has to be done on the topic, at least this is a start.

“Aaaahhh How Massage Therapy Can Help Nurses Reduce Stress” – Rose Kennedy

There has been lots of research put into Alzheimer’s disease and now there is new research showing that bacteria in the brain may be the cause, giving hope for new more successful treatments.

“We May Finally Know What Causes Alzheimer’s And How To Stop It” – Debora MacKenzie

While this is directed at gym owners, it can easily be adapted to your massage therapy clinic. Using social media is a major part of advertising these days and can be a useful tool for getting your targeted niche of a patient to use your clinic. Pick your targeted audience, and focus on it.

“Social Media For Your Gym – Pick A Lane And Stay In It” – Pete Dupuis

While I don’t agree with everything is this post, there are some valid points made. All too often manual therapists focus on strictly doing manual therapy. They avoid things like pain education, biopsychosocial aspects, lifestyle changes, and goal setting. All of these things as well as movement important aspects of being a therapist, so we can’t strictly rely on manual therapy, but I believe you can do a lot more than just a little bit.

“Manual Therapy Even A Little Bit Is Far Too Much” – Tom Belotti

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Here is some information I would like anyone with back pain to know. Whether it is the first time you have had back pain or you have had it for ages.

I would love others to contribute to building up this information as it is certainly not definitive. So if you are a clinician or have had back pain please email me if you have something to add ben@cor-kinetic.com

This has also been turned into a downloadable PDF so you can share with colleagues, patients or anyone you feel it may help. Please click Back Pain Share Pdf to get it!

Back Pain Information
  • Back pain is normal. Up to 20% of people are likely to get some each year and a whopping 80% of us will get some back pain in our lifetime, in fact, it would abnormal not to get back pain.
  • Back pain can last up to 6 weeks – this may be longer than you anticipated. So if it has been going on for a bit there is no need to unduly worry. Lots of pains only last a number of days but it is still normal for it to last longer.
  • Although we all know someone who has had long term persisting back pain that has caused lots of problems it is actually somewhere between 10% and 25% of people with back pain that lasts longer than normal. So you have good odds it won’t last longer than 6 weeks.
  • Back pain is no different to any other pain in our bodies such as shoulder, ankle or knee pain although people do tend to worry more about it.
  • Pain itself is normal and nothing to be scared of. It is a protective mechanism that has evolved to help us out. You would not want to live without it!
  • Pain is not good at reflecting the physical state of our back or any body part. We can have lots of pain without significant damage. Think about getting a paper cut or a bee sting. They can hurt like hell but don’t really damage us.

Diagnosis can often be challenging with back pain although I know that people often want an answer. We don’t always need a definitive answer to help you.

Here is what we do know:

  • The vast majority of back pain is not serious, in fact around 99%. The 1% is mostly fractures, can include cancer, but these a pretty rare occurrences.
  • Around 10% can be pinned down to a specific tissue diagnosis such as a disc or a nerve.
  • These statistics mean that it is unlikely to be a ‘slipped disc’ or a nerve problem and people often throw these terms around as causes without really knowing this for sure. This can often be unhelpful.
  • Therapists have some tests to tell if the problem is in that 10%. These include clinical tests for the nerves and nerve roots as well as muscle strength, sensation and reflex tests.
  • It is very difficult to make a diagnosis from an MRI alone. Lots of MRI findings also exist in people without pain, hence the need for a clinical exam to accompany a scan.
  • MRI’s are not able to show us pain.
  • So we often can’t pin it down to a specific tissue or pathology around 9 out of 10 times. There are lots of different tissues in a small space and if it is irritated or inflamed then it may affect more than one of the tissues.
  • Inflammation is a good thing. It means the body is working well and doing its repair jobs.
  • From a medical perspective, this type of back pain is often termed ‘non-specific’ and we should see this as a positive diagnosis as it means nothing serious is wrong. It could still hurt a whole lot though.
  • The term ‘non-specific’ means the tissue, not non-specific to you or has no origin. YOUR PAIN IS ALWAYS REAL AND SPECIFIC.
  • Non-specific pain often responds well to moving and although we cannot give an exact label does not mean we cannot give some ideas to help or a basic explanation about why you might have back pain.
Other Factors
  • Lots of different factors (many which you may have not considered) can affect your back pain.
  • This can mean that you feel your back pain has a life of its own but it may be that you have not been informed about or considered all of the potential contributing factors.
  • These other factors can include abnormal sleep, lots of life stressors including work and family, feeling that the pain will never go and negative beliefs about your back and performing daily activities.
  • Its probably not your spinal posture, your pelvic tilt, a teeny weeny muscle not firing or something needs to be put back into place causing your back pain. How do we know? We have studied this stuff to death.
  • If you have been told this before it could mean your therapist is not up to date with the latest research in this area. You may have been given lots of opinions previously and it can often be confusing for you and hence the need to be aware of the scientific data in this area.
  • There are NO magic treatments for back pain that work for everybody, unfortunately.
  • It might not be one singular problem but a few different things happening together. A minor pain might be exacerbated by other things that are making you a bit more sensitive.
  • Your therapist should be able to give you some basic advice or point you in the direction of others who can if it needs more specialist help.
  • Lots of different treatments can help in the short term, such as a few hours or days, but don’t simply put your recovery in someone else’s hands. This has been shown to often be worse in the long term.
  • You may have to avoid aggravating activities in the short term but make sure you go back to doing them. Nothing should be off limits in the long term. Don’t let anyone tell you otherwise.
  • People who feel they need to protect their backs can also have worse outcomes.
  • Learning more about what helps you and what makes you worse is important to help you manage your back pain. Your therapists should help you do this.
  • Movement and exercise might help.
  • Unfortunately, there are no magic exercises for back pain. Find what you enjoy and just do it. This could be Pilates, strength training, a sport with friends or simply going for a walk in the park.
  • Don’t feel you have to really push yourself to get stronger or fitter but it is good once in a while to exert yourself. This gets your body used to doing it.
  • Moving and exercising can help us build confidence in our bodies and this might be key to recovery rather than fixing a physical problem.
Persisting Back Pain
  • The common term for persisting pain is chronic pain, The term chronic does not mean ‘worse’ it is actually just a general term for pain that has gone on for longer than 3 months.
  • How we respond to back pain might play a role in how long it lasts. If you change what you do in terms of activity such as avoiding things or think very negatively about your pain and your recovery
  • We could see persisting back pain as our protective systems, in this case, pain, doing its job too well.
  • Although pain is normal and a good thing, we could see it a lot like red wine. A little bit is great, but sometimes we can have too much of a good thing and it leaves us with a hangover.
  • Persisting pain is currently seen as a problem of the protective system itself rather than simply reflective of the state of your body.
  • The more we work the mechanisms that contribute to pain the stronger they can get. It’s a bit like working your bicep in the gym. Just like your muscles the protective system can adapt and get better at protecting you.
  • Unfortunately, this means that the things that did not use to cause you pain now can do and may explain why you can be very sensitive to things that used to be normal.
  • All of this does not mean you can’t get better but it is not as simple as finding an ‘off’ switch.
Clinicians Advice
  • Sheren Gaulbert – Stay connected with people who matter in your life/engage in activities you value
  • Karen Litzy – Don’t consider yourself broken or damaged goods
  • Ash James – It’s often better to be at work than at home. You will move more, rest less, and get back to normal stuff sooner
  • Kjartan Vibe Fersum – Important to have a shared plan (with your therapist) to move forward with
  • Tom Goom – It’s good to experiment with movement, relax into it and see what helps pain and stiffness. Movement is medicine, and like medicine, it has a dosage, experimentation is needed to find the right dose for you
  • Claire Higgins – Your back is designed to be strong. It can so easily be visualized by patients to be a stack of blocks which could be “crushed” or “topple” at any moment. Education on how our backs are super strong and to trust in them is important.
  • Claire Higgins – Focus on the things which turn your pain down, restoring balance e.g. exercise, meeting friends for coffee, being in the great outdoors.
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As we progress towards a more evidence-based practice both personally and hopefully overall as a profession, new opportunities will continue to open up for massage therapy. Part of this is being able to explain to patients exactly what we do and what we offer. Here are four science-backed ways we can do so.

“4 Science-Backed Ways Massage Therapy Helps People Feel Better” – Richard Lebert

When it comes to manual therapy there is any number of courses and teachings centered around techniques of touching people in different ways. However, what is really important is touch and narrative. We often focus on what we hope are specific effects, but the non-specific may be more important.

“Clinical Reasoning In Manual Therapy” – Nick Efthimiou

Research is showing that slow gentle stroking of the skin can be an effective way to reduce feelings of social exclusion. While it didn’t completely eliminate the feelings of exclusion, it did help.

“Gentle Touch Soothes The Pain Of Social Rejection” – Science Daily

Researchers in Sweden have shown that nerve endings in our fingertips actually encode information about touch intensity and shape before it even reaches the brain. Probably why you can do some treatments on autopilot, letting your hands feel their way through the treatment.

“Your Fingertips Perform Brain Like Calculations” – Carl Engelking

As therapists, we regularly talk to our patients about their homecare and taking care of themselves, to be kind to themselves. But, how often do we take our own advice? If we are kind to ourselves, we can actually treat others better as a result.

“The Heart And Science Of Kindness” – Melissa Brodrick

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He came in with a look that resembled someone in grief.

I asked if he was okay and his response was a bit surprising.

“I was just told I have a disease which is causing my back pain, as a result, the pain may never go away.”

As I inquired more he told me the diagnosis was degenerative disc disease, which was causing his spine to shrink and as a result, it was causing the low back pain he was experiencing and would now have to seek treatment on a weekly basis just to deal with it.

This once active person (in his 50’s) was now disheveled because of this MRI diagnosis he had been given by another practitioner, he felt hopeless.

Why MRI Is Just One Tool That Should Be Used

Stories like this happen all too often with our patients.

They experience some sort of low back pain, (which usually they have never experienced before) and their doctor or other healthcare practitioner orders an x-ray or MRI and the results seem catastrophic. They are diagnosed with a “disease” or “syndrome” of some sort but aren’t given any really good information surrounding their condition.

While there is a possibility that disc degeneration (DDD) could be a contributing factor to their pain, it’s not as simple as just looking at some medical imaging to get a proper diagnosis.

There are several contributing factors including environmental factors, genetics, and associations with heavy physical work, lifting, truck-driving, obesity and smoking (smoking has been found as a risk factor for pain and DDD) found to be the major risk factors. However, these do not point to a clear pattern between degeneration and clinical symptoms.

Something that doesn’t get mentioned as often, is how this is also simply a part of normal aging. One systematic review points out some interesting facts to show just how much this happens. When looking at 3110 images of asymptomatic people the review showed: 

  • Prevalence of disc degeneration in people at 20 years old was 37% which increased to 96% in 80-year-olds.
  • Disc bulges occurred in 30% of people at 20 years old and 84% in those at 80 years of age.
  • Disc protrusions were 29% of 20-years-old and 43% of 80-years-old.

And all of these individuals weren’t experiencing any pain!!

Another study showed changes in the disc at multiple levels were more common in the elderly (in this case above 60 years) as well as other degenerative changes around the facet joints, ligamentum flavum, and disc bulges.

Even though degeneration has been seen in the younger population as well, there is little correlation between radiological findings and pain. Quite often people whose imaging shows major issues have no pain and those who present with minor signs experience severe pain.

Unfortunately, many of these people are referred for surgery (usually a spinal fusion) which eliminates motion and can lead to degeneration of adjacent parts of the spine. Another part of the problem here is this only addresses a symptom, not the cause and the surgical outcomes are not great. It is also important to note that 70-80% of people who have surgical indications for back pain or disc herniation recover whether they have surgery or not.

These surgical referrals usually happen because imaging has been used as a diagnosis, rather than just a tool used in the process. This isn’t to say imaging shouldn’t be used, but it should not be the only thing used. Overall we see the association between MRI findings and DDD are unreliable, so the importance remains on our clinical reasoning and of course, patient history as well as looking for any neurological deficits.

The Role Of Depression

Now that we understand DDD risk factors, it’s age-related changes, and correlation with pain there is another factor we need to look at. 


In a three year study looking at veterans who were asymptomatic with low back pain, they were given repeated MRI’s over this three-year span. The researchers made a point of not telling the participants the results of what they saw as they didn’t want the patients to alter their symptoms by becoming sensitized to trivial issues or amplifying their symptoms. 

Imaging findings varied, some discs were less severe, or even normal, and some became worse. The study concluded that central stenosis, nerve root contact, and disc extrusion were the most important imaging findings that may be risk factors for future back pain, however, protrusions were not a risk factor. 

But, the strongest predictor for low back pain was depression. 

Of those who self-identified (and were being medically treated for it) as having depression, their pain scores were greater at EVERY follow-up, whereas the progression of disc changes was only occasionally associated with new pain. Some of the participants also pointed out their activities were limited because of their depression. 

As we know (when reviewing the clinical guidelines of low back pain) bed rest used to be one of the main recommendations for those dealing with acute low back pain, but now exercise and movement is the far better recommendation. When we look at discs exercise does not affect them adversely and they respond well to long term loading strategies. 

So, think about that patient who comes in and is catastrophizing about the diagnosis they have just received. We know part of what we have to do is provide reassurance, in fact, this is a MAJOR part of what we have to do. Looking at all the information we have just discussed, letting them know that disc degeneration is a part of normal aging, there is little correlation between their diagnosis and pain (unless there are neurological symptoms) and quite often the issue resolves itself without surgery. Could we actually reverse their catastrophizing? Could we also assist this by encouraging them to exercise, even by getting them moving on your table to show that movement is safe? We know that exercise has great results in helping with depression and now we know it also helps with disc health, so aren’t these the things we should pay more attention to rather than focusing on MRI results? I’d say yes…and the research agrees. 

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People will do all sorts of popular treatments for different parts of their body. There is a new trend where women are getting laser therapy on their vagina for a variety of reasons, but is the treatment actually valid? Well…there is still research to be done.

“Do Vaginas Need Rejuvenating?” – Sandy Hilton

Patient education and communication is a crucial part of treatment, but how much of what we say do they remember? This is where effective communication may be using short simple messages to help with education retention.

“Pain Science Education” – Lynita White

When it comes to our mental health, it turns out exercise does more for it than money. Although I’m sure most of us would have guessed that, there’s actually research out of Yale and Oxford that prove it.

“Exercise Makes You Happier Than Money” – Ruqayyah Moynihan

Continuing with mental health, how about its relationship with food? If we were to include education on nutrition as part of mainstream healthcare is there a potential for real change? This article argues it would.

“Why Isn’t Nutritional Therapy A Primary Therapy For Mental Illness?” – Eirik Garnas

Research is showing us that one of the best things we can do for arthritis, is loading the affected joints. When loaded properly we can actually combat the effects arthritis has on the joints.

“Arthritis And Movement: Your Weightlifting Prescription” – Mike DeMille, DPT, and Erin Murray

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Sometimes a patient walks into your clinic and it’s hard to decipher what’s going on with them.

It may be something we’ve never seen before, their signs and symptoms don’t add up, or their pain doesn’t seem to correlate to their description of the cause. When things don’t seem to add up, our clinical reasoning has to jump into full effect to figure out what’s going on.

Looking at the red flags of low back pain, one of the conditions that really stands out is Cauda Equina Syndrome.

While it is rarely seen in practice (I have yet to ever encounter a patient with it) it is something we should have a working knowledge of, so our clinical reasoning can jump into action.

Early recognition and referral to medical help can make a massive difference in its development and effect on a patient, so we have a responsibility to recognize and refer out when necessary, and in this case, it is!

Recognizing Cauda Equina

The Cauda Equina is a bundle of nerve roots that angle down in the vertebral canal from the end of the spinal cord, which looks like wisps of hair, giving it its name, meaning “horse’s tail”.

What causes Cauda Equina Syndrome is usually some sort of compression happening at the nerve roots around the lumbar to sacral area. The most common causes are:

  • Lumbar disc herniation, prolapse, or sequestration (one systematic review showed 45% were disc related)
  • Smaller prolapses due to spinal stenosis.

The less common causes are:

  • Epidural Haematoma.
  • Infection.
  • Primary and metastatic neoplasms.
  • Trauma.
  • Post-surgical.
  • Prolapse due to manipulation.
  • Chemonucleolysis.
  • After spinal anesthesia.
  • Patients with Ankylosing Spondylitis.
  • Gunshot wounds.
  • Constipation.

All of these things are important to ask during a patient history if you suspect a possibility of Cauda Equina, but more important is their clinical presentation. It may present as: 

  • Low back pain.
  • Saddle anesthesia.
  • Bilateral sciatica.
  • Weakness of their lower extremities.
  • Paraplegia.
  • Bowel, bladder, or sexual dysfunction.

The most commonly seen are low back pain and radicular leg pain because of tissue irritation around the lumbar spine.

When it comes to assessing patients who could possibly be dealing with this, one review showed they can be placed into three groups: 

  1. CESS (Cauda Equina Syndrome Suspicious or Suspected)
    • Bilateral radiculopathy.
    • Subjective sphincteric problems with no objective evidence of CES.
  2. CESI
    • Subjective symptoms and objective signs, but voluntary control of urination.
  3. CESR (Cauda Equina Syndrome Retention)
    • Neurogenic retention of urine with a paralyzed, insensate bladder along with urinary incontinence.

Now just as we see some “red flags” with low back pain, CES has also been divided into red flags and white flags and are divided into:

  • Definite Red Flags
    • Bilateral Radiculopathy.
    • Progressive neurological deficit in the legs.
  • Possible Red or White Flags
    • Impaired perineal sensation.
    • Impaired anal tone (not that I’m suggesting you should ever try to palpate this).
    • Urinary difficulties that are unspecified.
  • Definite White Flags
    • Urinary retention or incontinence.
    • Fecal incontinence.
    • Perineal anesthesia.

With this outline, we define the “true red flags” as someone who has bilateral radiculopathy, difficulties with urinating, or changes in bladder function, along with the loss of perineal sensation. However, there is nothing that gives a clear diagnosis because so many of the symptoms are objective. It is recommended that MRI is important, not because it can diagnose, but rather it shows which people with red flag symptoms have significant compression of the nerve roots, which may result in treatment before the development of the white flags which are more severe.

White flags are a way of saying “defeat or surrender” as the signs are often seen too late and are irreversible. Therefore the review outlining these red and white flags makes the argument that white flags should be removed because treatment at this stage might be too late to recover and avoid long term harm.

Another review even pointed out these different subclasses were too ambiguous as far as signs any symptoms go, so they should be avoided as well.

Then the argument is made that CES diagnosis should revolve around one or more of the following being present:  bladder or bowel dysfunction, reduced sensation in the saddle area, and sexual dysfunction with possible lower limb neurologic deficits.

Clear Communication And Reassurance

As we have talked about before, when it comes to low back pain, patient reassurance is a crucial aspect of helping them deal with these issues.

Much of the evidence shows good outcomes occur when patients have decompressive surgery early before there are incomplete lesions on the nerve. However, it is unclear as to which exact surgery (there are a few different types) works the best and is another factor that could affect patient outcomes.

So the important thing is for us to recognize these symptoms, realize there is an issue, and have our patients get the appropriate help, (which is most likely a trip to the hospital), as early recognition and treatment is key.

We want to ensure when talking to our patients that we are using clear and easily understandable terms, as well as proper descriptive terms when referring to doctors as this is a rare condition and is estimated a doctor may only see this once in their career.

It is crucial that our communication with patients is centered on them, not only in the way we talk, but also in the way we listen, as it has been shown they use very explicit language in their description of symptoms. It is then important for us to use terms they understand. Much of the research uses terms like “micturition” and “incontinence” which came across as very vague and hard to understand for patients. Rather, using terms like “urinating”, or “difficulties using the restroom” would be more appropriate. One patient was told their issue was serious if they were incontinent, yet the patient would be able to “force” themselves to use the toilet, so didn’t understand this was an issue.

So, clear communication is key to the emphasis and seriousness of their condition, as well as the importance of getting to the hospital quickly (better outcomes within 48 hours of recognition and treatment). While these can be difficult conversations to have, they are crucial ones because if this isn’t recognized and dealt with, there can be long term and VERY undesirable consequences, which are quite simply life altering. We can play a major role in this for our patients. While it may be difficult to have conversations (and some would argue we shouldn’t) centered around sexual dysfunction and using the toilet, we owe it to our patients as healthcare professionals to not only be open to,  but willing to talk about this for their better outcome.

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