Thoughts... Pain, Ice, Persistence with your Exercises, etc

Thoughts by Dr. Lew, DC, DACRB ... 

Table of Contents of this page (as of 12/17/2017)

• Low Back Pain
• Exercises that help Low Back Pain
• Ice IS GOOD for pain relief

Some thoughts on Rehab for Low Back Pain

Summer 2012 

Back pain sucks. Sorry, but if you've experienced it, you already know that and I hope you forgive my language. I speak about this from the perspective of the patient as well as the chiropractor and rehabilitative exercise coach. 

I have been teaching a new class on rehab- the focus is on how to support people recovering from low back pain and how to prevent low back injuries. During my studies, I injured my low back (by sitting too much prepping for the class by  making PowerPoint presentations- big cup of irony swallowed). I also came across some stuff that I applied to myself that were amazing in my recovery... so here is what I think everyone should know now about low backs…

1. Low backs often hurt from all the sitting- it's like extending your wrist with your palm on the floor when doing a push up. Would we be able to do that for more than 5 minutes? No. So perhaps we should wonder why we think sitting in flexion for hours is okay for our low backs.
2. A strong core helps low backs from getting fatigued and prevents injury as well as helps decrease low back pain due to muscle fatigue.
3. Crunches and pelvic tilts where the low back is flattened on the ground is not good for the lumbar discs- it puts 2x plus pressure on the discs.
4. The posterior aspect of the disc- the annulus fibrosus can have stretch injuries or tears as well as fissures from the outer aspect to the inside aspect. This is in addition to the popular "slipped disc" which of course isn't slipped at all, but is a bulging or protrusion of the center of the disc's nucleus pulposus material. A stretch injury is like the one that you imagined happened to the wrist when doing a prolonged push up. It will be a deep pain and cause all the surrounding muscles to go into spasm in an attempt to protect the painful area.
5. The annular fibrosus stretch injury pain is a deep, hard to pinpoint pain because it is innervated by the recurrent meningeal nerve which is not the same innervation as the facet joint innervation. The facet joint is innervated by the medial branch of the posterior primary rami of the spinal nerve. This same medial branch also innervates the ligaments between the spinous processes and this may be why we feel pain between our spinouses when we need a facet joint adjustment. And this also may explain why after the "pop" sound of a vertebral facet joint chiropractic adjustment, the pain between the spinouses is less.
6. There are some very simple exercises one can do to gradually increase muscle endurance in the low back and abdominal core. The primary ones are called the McGill Big 3
7. The McGill Big 3

1- McGill Curl Up

2- Side Bridges

3- Bird Dogs

With all of these, the most important thing is the QUALITY OF MOVEMENT and the SYMMETRY (right and left look similar). Generally I suggest you start each of these with a goal to do it for 3-5 seconds with a 5 second rest in between to 3-5x per side per day. The progression should be to get to 5-10 second holds and 10-20x per side per day.

Here are links to Professor Stuart McGill's videos, articles, and audio interviews on how to get a stronger abdominal core and low back without hurting the lumbar disc.

The audio interview is 84 minutes long and one of the best I've ever heard:

http://www.backfitpro.com/media/interview.mp3 

(if that doesn't work, go to his main webpage  http://www.backfitpro.com/  and click on the link.)

The video is only a few minutes long and summarizes what the McGill Big 3 are.

http://youtu.be/qsup3ZvzAjU   (5:57 min)

(times listed are when they occur in the video)

1:30 McGill Curl Up- this is a low stress abdominal core strengthener

2:20 Side Bridge- essential to strengthen the quadratus lumborum and latissimus dorsi

2:48 Bird Dog- low stress low back strengthener

after that he demonstrates some higher levels you can progress to.

The goal is again to stiffen the core, maintain quality and control.

And lastly, here is an excellent article by Prf. McGill

http://www.acefitness.org/pdfs/LowBackStabilization.pdf

There you have it, this is what I teach my students to do themselves and what to teach to their future patients.

Sincerely,

Dr Lew

originally posted on Dr. Lew's old Palmer website 9/3/2012, modified 1/1/2013

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Patience and Persistence are the keys to recovery

Here are the rules

1) NO SITTING!

2) NO BENDING (for right now)

3) Brace your abdomen with your muscles when doing everything.

Learn to do this by doing Dead Bug Wall Pushes- lie on the floor with your head 6 inches from the wall. Start with knees bent and feet on the floor. Push on the wall above your head with both hands. Feel your belly/abdomen brace. Now put your feet in the air- hips, knees and ankles at 90 degrees. Push again on the wall above your head. Feel how strong your belly/abdomen feels? Now try tapping your heels one at a time on the floor (keep your knees and ankles at 90 degrees). Add the wall push. See how much easier it is to do the heel taps when you brace by pushing on the wall. Lastly, learn to brace (or pull your rib cage down without flattening your spine against the floor) without needing to push on the wall. That is Abdominal Bracing and that will save your spine!

3) Start with these exercises today. If any hurt, stop and modify or don’t do them

McGill Curl Ups – 10 at 10 second holds per day

Dead Bug Wall Pushes – 10 at 10 second holds per day

Side Bridges – (on the knees, not ankles)- 5 at 10 second holds per side per day

Once those become easier

Add heel taps to the Dead Bug Wall Pushes

Try Side Planks (on ankles)

Add a lightweight Thera-Band (red or green) on a hook on the wall at about 3 feet up from the floor. Lie on the floor with your head about a foot from the wall with one leg straight on the floor and the other one with the knee bent and foot on the floor. Thread the Thera-Band through the wall hook and hold on to the band ends with each hand. Brace your belly/abdomen and then with both hands simultaneously pull the band down to touch the floor next to your hips. Remember to breath and Brace!

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ICE therapy IS still good!  – Especially for my patients!!

Public Commentary by Dr. Makani Lew, BSc, DC on ICE and how it can be ESSENTIAL in patient healing to use ice.

Last edited 5/11/2014

~In health to all, Dr. Lew, DC~

This is in response to several blogs and an article saying we approached the end of the RICE era:

http://drmirkin.com/fitness/why-ice-delays-recovery.html  (from the man who created “RICE” in acute care)

http://stoneathleticmedicine.com/2014/04/rice-the-end-of-an-ice-age/

http://www.mobilitywod.com/2012/08/people-weve-got-to-stop-icing-we-were-wrong-sooo-wrong/

In a nutshell, the articles question the use of ice because it appears to reduce the normal metabolic effects of the healing properties of inflammation.

This Ice-hating is a subject that I've been planning to address officially through various written journals. In the meantime, here is what I have so far.

I've been very disturbed about the jump on the bandwagon against ICE movement. As a person who has been studying ice and its effects since 1991, I feel I come to the table with a degree of authority. Furthermore, it seems in most of these studies there is no accounting for the amount of NSAIDs or SAIDs taken for pain. 

Here are my current thoughts:

1) The first question is what is the goal?

a) Decrease pain and/or

b) Decrease swelling

c) Hasten healing (Does it? this is the one that is in question- based on a Bleakley 2004 systematic review of in-hospital injury care. Bleakley C, McDonough S, and MacAuley D. The use of ice in the treatment of acute soft-tissue injury: a systematic review of randomized controlled trials. Am J Sports Med January 2004 32 251-261. http://ajs.sagepub.com/content/32/1/251.abstract HOWEVER, has anyone seen the ice pack appropriately applied in the hospital recently?? I have not. It is usually draped over the area that is in a stabilizer brace. And the cold cannot penetrate the cast material.)

2) The second question is: who is the patient?

Here is what I think the basic formula for patient type is. (Combinations of these, of course, exist):

a) A fit athlete performing a strenuous athletic endeavor?

b) A person attempting new fitness activities?

c) An average person who was injured by a rapid trauma?

d) An average person who was injured by a repetitive use or repetitive posture trauma

3) I believe that reducing pain and swelling in the first 24 hours is key to the outcome of the injury.

a) Ice is known to reduce interstitial swelling ONLY in the first 24-48 hours

b) Reduction of the initial swelling will reduce secondary tissue damage due to tissue distension

c) Reduction in swelling is dramatically increased with compression

d) Remember: heat transfers from hot to cold and not vice versa. Therefore Application of a cold object will in effect draw the blood flow and “heat” of inflammation out to the surface. This is why a bigger body part or more several injury (eg quads contusion) takes longer to get “numb”. Pulling the blood out will cause the internal swelling to be reduced (superficial venous drainage).

e) Cooling of the tissues will reduce the NCV (nerve conduction velocity), thereby reducing the sensation of pain

4) What about the analgesic properties of ice? Why provide “pain relief”?

a) Decreasing pain naturally is my primary goal- so if I can take a person from writhing in pain and going into adrenal overload (and therefore sympathetically induced muscle tightness “spasms” and anxiety), I feel the metabolism issues are less vital.

b) A few minutes of pain relief can provide a bridge to sleep, muscle relaxation, more open-mind for mindfulness healing and so much more. 

5) Are pharmaceutical anti-inflammatories the answer? If the argument against ice is that it messes with normal inflammation and tissue metabolism, then we should avoid the following as well

a) NSAIDs (The risk of serious gastro-intestinal ulcer complications is about 2.5-4.5 higher in NSAID users than in non-NSAID-users. Zhang, W. (2007) NSAIDs and Pain Management in Sports, in Evidence-based Sports Medicine, Second Edition (eds D. MacAuley and T. M. Best), Blackwell Publishing, Malden, Massachusetts, USA.) http://onlinelibrary.wiley.com/doi/10.1002/9780470988732.ch13/summary

b) SAIDs

6) What about using heat on the acute injury?

a) A well-done study showed that heat or ice on a swollen sprained ankle in the first few days showed same 6-month outcomes in terms of "back on the field" abilities.

b) However, use of heat will increase the swelling and thereby the secondary tissue damage

7) What other types of modalities help? (appear to decrease initial inflammation overload?) * means there appears to be supportive evidence, x means there appears to be evidence that the modality doesn't do as we once thought, - means that evidence is either lacking or being gathered at present.

a) Cold-laser (3b) *

b) Pulsed ultrasound x

c) Microcurrent -

d) IASTM (Instrument-Assisted Soft Tissue Massage) -

(Graston, FAKTR (Functional and Kinetic Treatment with Rehab), Tecnica Gavilan, etc)

e) Kinesiotape/Rocktape/etc edema strips (RockTape, Kinesiotape, KT Tape, Spider Tech) -

f) Voodoo flossing -

g) Careful low range of movement of an mild to moderately injured body part *

Bleakley C. Effect of accelerated rehabilitation on function after ankle sprain: RCT 2010    http://www.bmj.com/content/340/bmj.c1964.pdf%2Bhtml

h) Epsom salts soaks (mostly athlete and grandmother anecdotal evidence on this) -

i) ??? (there must be more out there!)

8) If I do still decide to ice, what ice set up is best?

a) It is patient dependent- size of limb/body part, patient gender, patient fitness level, patient preference

b) NEVER Ice longer than the first indication of numbness

c) Bags of ice are the safest

d) Wet ice is better- add a wet towel between the ice bag and the skin

e) Addition of compression is essential in controlling swelling (not too tight/not too loose)

f) Couple the cryotherapy with other supportive modalities (listed above)

So, I conclude: as a drug-free practitioner, are we not always seeking ways to reduce pain and the anxiety of pain? I believe that ice still plays a key role especially in the first 2 days. Period.

References:

I am sorry I haven’t included in this commentary all the reference links to each of the above statements (yet). I recently did a research platform presentation on findings from a study conducted on the Palmer College of Chiropractic West Campus titled Time to numbness in response to 5 different cryotherapy applications.

Here is a link to my platform abstract: http://www.journalchiroed.com/doi/pdf/10.7899/JCE-14-3  

(To request a handout from my ACC-RAC 2014 platform presentation, send an email to:  Makani.lew@palmer.edu (Be put in the email subject:  “requesting copy of Ice handout” and provide an explanation of your request in the email text body.)

Here is my Platform Presentation Reference list.

(This is, of course, not a complete list of references that I turn to regarding the subject of ice)

Agafly A and George K. The effect of cryotherapy on nerve conduction velocity, pain threshold and pain tolerance. Br J Sports Med 2007;41:365-9.

Belanger A. Chapter 8: Cryotherapy in Therapeutic Electrophysical Agents: Evidence Behind Practice. Lippincott Williams and Wilkins, Philadelphia, 2010.

Belitsky R, Odam S, and Hubley-Kozey C. Evaluation of effectiveness of wet ice, dry ice, and cryogen packs in reducing skin temperature. Phys Ther 1987;67(7):1080-1084.

Bleakley C and Hopkins J. Is it possible to achieve optimal levels of tissue cooling in cryotherapy? Phys Ther Rev 2010;15(4):344-50

Bleakley C and MacAuley D. Chapter 11: What is the role of ice in soft-tissue injury management? In MacAuley D and Best T. Evidence-Based Sports Medicine. Evidence-Based Sports Medicine, 2nd

ed. BMJ Books London. 2007.

Bleakley C, McDonough S, and MacAuley D. Cryotherapy for acute ankle sprains: a randomized controlled study of two different icing protocols. Br J Sports Med 2006;40:700-5.

Bleakley C, McDonough S, Gardner E, Baxter GD, Hopkins JTy, and Davison GW. Cold-immersion for preventing and treating muscle soreness after exercise. Cochrane Database Syst Rev 2012 Feb 15;2:CD008262.

Cameron M. Chapter 8: Superficial Cold and Heat in Physical Agents in Rehabilitation: From Research to Practice, 4th ed., Saunders, Philadelphia, 2013.

Denegar C. Chapter 8: Cold and Superficial Heat in Therapeutic Modalities for Musculoskeletal Injuries, 3rd ed., Human Kinetics Publishers, Champaign, 2010.

Dykstra J, Hill H, Miller M, Cheatham C, Michael T, and Baker R. Comparisons of cubed ice, crushed ice, and wetted ice on intramuscular and surface temperature changes. J Athl Train 2009;44(2):136–41.

Enwemeka C, Allen C, Avila P, Bina J, Konrade J, and Munns S. Soft tissue thermodynamics before, during and after cold pack therapy. Med Sci Sports Exerc 2001;34(1):45-50.

Frute S. in Michlovitz S, Bellow J, and Nolan T. Chapter 2: Cold Therapy in Modalities for Therapeutic Intervention, 5th Ed., FA Davis, Philadelphia, 2012.

Graham C and Stevenson J. Frozen chips: an unusual cause of severe frostbite. Br J Sports Med 2000;34:382-4.

Herrera E, Sandoval M, Camargo D, and Salvini T. Motor and sensory nerve conductions are affected differently by ice pack, ice massage, and cold water immersion. Phys Ther 2010;90(4):581-91.

Hocutt J, Jaffe R, Rylander R, Beebe K. Cryotherapy in ankle sprains. Am J Sports Med 1982;10(5):316-9.

Hopkins JT, Knee joint effusion and cryotherapy alter lower chain kinetics and muscle activity. J Athl Train 2006;41(2):177-84.

Hubbard T, Aronson S, and Denegar C. Does cryotherapy hasten to participation? A systematic review. J Athl Train 2004;39(1):88-9.

Jutte L, Hawkins J, Miller K, Long B, and Knight K. Skinfold thickness at 8 common cryotherapy sites in various athletic populations. J Athl Train 2012;47(2):170-7.

Jutte L, Merrick M, Ingersoll C, and Edwards J. The relationship between intramuscular temperature, skin temperature, and adipose thickness during cryotherapy and rewarming. Arch Phys Med Rehabil 2001;82:845-50.

Kanlayanaphotporn R and Janwantanakul P. Comparison of skin surface temperature during the application of various cryotherapy modalities. Arch Phys Med Rehabil 2005;86:1411-5.

Knight K and Draper D. Chapter 13: Cryotherapy, Beyond Immediate Care in Therapeutic Modalities, the Art and Science, 2nd ed., Lippincott Williams and Wilkins, 2012.

Knight K and Draper D. Chapter 5: Immediate care in acute orthopedic injuries in Therapeutic Modalities, the Art and Science, 2nd ed., Lippincott Williams and Wilkins, 2012.

Knight K. Cryotherapy: Theory, Technique and Physiology, 1st ed., Human Kinetics Publishers, Champaign, 1985.

MacAuley D. Chapter 4: What is the role of ice in soft tissue injury management?  In MacAuley D and Best T. Evidence-Based Sports Medicine. Evidence-Based Sports Medicine, 2nd ed. BMJ Books London. 2002.

MacAuley D. Do textbooks agree on their advice on ice? Clin J Sport Med 2001;11(2):67-72.

Merrick M, Knight K, Ingersoll C, and Potteiger J. The effects of ice and compressive wraps on intramuscular temperatures at various depths. J Athl Train 1993;28(3):236-245.

Merrick M. Chapter 8: Therapeutic Modalities as an Adjunct to Rehabilitation in Andrews J, Harrelson G, and Wilk K. Physical Rehabilitation of the Injured Athlete, 4th ed., Elsevier Saunders, Philadephia, PA, 2012.

Myrer J, Measom G, and Fellingham G. Temperature Changes in the Human Leg During and After Two Methods of Cryotherapy. J Athl Train 1998;33(1):25-9.

Nadler S, Prybicien M, Malanga G, and Sicher D. Complications from therapeutic modalities: results of a national survey of athletic trainers. Arch Phys Med Rehabil 2003;84:849-53.

Otte J, Merrick M, Ingersoll C, and Cordova M. Subcutaneous adipose tissue thickness alters cooling time during cryotherapy. Arch Phys Med Rehabil 2002;83:1501-5.

Park G, Kim C, Park S, Kim M, and Jang S. Reliability and usefulness of the pressure pain threshold measurement in patients with myofascial pain. Ann Rehabil Med 2011; 35: 412-7.

Rupp K, Herman D, Hertel J, and Saliba S. Intramuscular temperature changes during and after two different cryotherapy interventions in healthy individuals. J Orthop Sports Phys Ther 2012;42(8):731-7.

Starkey C. Chapter 5: Thermal Modalities in Therapeutic Modalities, 4th ed. FA Davis, Philadelphia, PA, 2013.

Tegeder I, Adolph J, Schmidt H, Woolf C. Geisslinger G, and Lotsch J. Reduced hyperalgesia in homozygous carriers of a GTP cyclohydrolase 1 haplotype. Eur J Pain 12 (2008) 1069-77.

Tomchuk D, Rubley M, Holcomb W. Guadagnoli M, and Tarno J. The magnitude of tissue cooling during cryotherapy with varied types of compression. J Athl Train 2010;45(3):230-7.

Ungar E and Stroud K. A new approach to defining human touch temperature standards. NASA, Johnson Space Center, Houston, TX Conference Proceedings, 2010 http://ntrs.nasa.gov

Zemke J, Andersen J, Guion WK, McMillan J, and Joyner B. Intramuscular temperature responses in the human leg to two forms of cryotherapy: ice massage and ice bag. J Ortho Sports Phys Ther 1998;27(4):301-7.

Here is a link to my PubMed list of refs- it is constantly updated and growing:

Also, if the text is housed on PubMed, it can’t be linked to this list. So some excellent resources aren’t on my list. http://www.ncbi.nlm.nih.gov/sites/myncbi/collections/public/16i7Yydou44OA3m7KwajARX5I/

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