Back pain and running – acute management advice

Today's blog is the start of a series on lower back pain (LBP). It's a complex area and so needs to be looked at over several blogs instead of one monster blog!

The first question with a back problem should be should I seek medical advice? The aim of this article is to help you answer this question.

Pain from the lower back can be severe and distressing but in most cases it is not due to serious disease or damage. The spine is a strong, stable structure that is unlikely to be harmed by normal everyday activities.

RunningPhysio always recommends seeking medical advice for injuries, and this is especially true with LBP. That said, approximately 80-90% of us will have back pain at some point and not everyone will choose to see the GP. Ultimately it's always your decision, but here is some guidance;

Likely to resolve with self management

  • Pain is only in the lower back and doesn't spread into the buttocks, legs or feet
  • Pain is mild to moderate in intensity (if rated out of 10 where 10 is the worst possible pain, you'd rate it 1-6)
  • No pins and needles, numbness or unusual symptoms
  • You can ease your pain in certain positions or using medications
  • You're generally well in yourself

Action – general back pain management advice (below) consult with GP/ Health Professional if pain worsens or doesn't settle in 6-8 weeks. As ever if in doubt get it checked out.

Definitely see GP/ Health Professional if…

  • Pain is more severe (you'd rate it 5-10 out of 10)
  • Symptoms spread into buttocks, legs or feet
  • You experience pins and needles or numbness in one or both legs or feet
  • Leg/s feels weak or heavy.
  • Pain is constant or harder to settle
  • Your pain started following a mild/ moderate trauma – heavy lifting, turning in bed
  • You have any previous history of cancer, TB or rheumatological conditions or your general health has deteriorated since your back pain started (especially if you have weight loss, night sweats, nausea or vomiting)

Action – see your GP or a health professional. Back pain with leg pain is a sign of inflammation around a nerve, especially if accompanied with pins and needles or numbness or weakness in the leg.

Attend A&E if along with back pain you experience…

  • Urine retention – feeling the need to pass urine but being unable to go
  • Faecal incontinence – losing control of bowel movements
  • Saddle paraesthesia – pins and needles or numbness in the groin and between your legs, may also include erectile or sexual dysfunction.
  • Gait disturbance – legs feel wobbly or unsteady and it's affecting your walking.
  • Your pain started after serious trauma – RTA, fall from height, heavy collision during sport etc.

Action – head to Accident and Emergency (A&E) immediately. The above symptoms suggest more serious injury that needs immediate medical attention. There are a group of nerves in the lower back called 'cauda equina' these nerves supply the parts of the bladder and bowel involved in passing urine and faeces. If there is compression to these nerves and it's not addressed quickly it can have long term implications on bladder, bowel and sexual function. Thankfully this is rare, a study in 2007 estimated that it affects just 3.4 people per 1.5 million of the population. In my 10 year career I've only had to send 1 patient to A&E with suspected cauda equina compression.

General Back Pain Management Advice

Stay active – try and stay active where possible, this might include walking, cycling, gentle gym work or swimming you can do this by pacing yourself…

Pace yourself – often the key to managing pain is doing the right amount of activity, too much and you can get sore, too little and you can get stiff and weak. Pacing means doing as much activity as you can manage, usually this means 'little and often' rather than lots at a time. Gritting your teeth and pushing on through pain will often make pain worse. If you can run without pain (during or after) then you can continue to do so but don't over do it – stick with gentle comfortable runs. Ideally you should be within the first category mentioned above ('Likely to resolve with self management') if not then consult your GP or health professional before returning to running.

Stay positive – the majority of low back pain settles in 6-8 weeks and can still be treated well beyond this stage. Keep a positive attitude and bare in mind severe pain doesn't mean severe damage. The back is a sensitive area with multiple nerves which mean you can get severe pain there, even in the absence of significant damage.

Continue working – taking prolonged periods of time off work doesn't always help back pain. When off work we tend to be less active and spend more time sat and the back stiffens and gets worse as a result. People that continue working usually tend to do better than those that stop. That said, jobs that involve very heavy lifting may prove very difficult – in which case request a period of time on light duties rather than stopping work altogether.

Avoid bed rest and prolonged periods of inactivity – the old advice of taking to your bed or sleeping on cupboard door has been shown to cause more problems than it solves! Long periods of sitting, standing or lying in bed tend to make pain worse. Most people do a lot better by staying active.

Use appropriate pain relief – many people are reluctant to take pain relief incase it 'masks damage to the back' (I.e. they worry they will damage their back if they use analgesia to reduce pain), this is not the case. Pain relief allows people to stay mobile which prevents the back becoming weak and tight. Movement is good for the back (as long as you don't over do it) pace yourself and do what you can.

Try to settle symptoms – use heat/ ice, gently massage the area, try a few gentle back movements, have a swim, sauna or jacuzzi – see what works for you to settle your symptoms.

More information available here including some gentle exercises to try.

Final thoughts; back pain is very common and in the vast majority of cases does not involve serious disease or damage. The back is a strong stable structure, supported by strong ligaments and muscles and is capable of managing day to day activities. Most acute back pain will settle in 6-8 weeks, stay active, pace yourself and keep positive to help with a speedy recovery.

Part 2 coming soon – causes and solutions for back pain in runners.

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Acute injury management – do no HARM?

It seems medical folk love a good acronym! We’ve had 3 already in managing acute injury. First we had RICE, then PRICE and then POLICE. I wonder if they just think up the word then fit the advice into it!?

What’s next Mobilisation Avoid NSAIDs Load Optimally Vertically Elevate? I can see it now on the RW Forum’s….”acute injury? What you need is MANLOVE!”….

Sadly manlove isn’t a recognised acronym in acute pain. Yet….

HARM though is a recognised acronym and details the things to avoid in the first 72 hours following an injury;

  • Heat
  • Alcohol
  • Running (or Re-injury depending on what version you use, both mean avoid excessive exercise)
  • Massage

I’ve highlighted avoid there in case you all get the wrong end of the stick and run around drunk with heat packs strapped to you, trying to massage each other!

 

What they say makes sense and is a helpful addition to the recommendations of POLICE and suggestions on use of NSAIDs.


Heat is thought to increase blood flow by causing blood vessels to dilate. This could lead to increased bleeding and swelling.

 

Alcohol is also likely to increase bleeding and may delay healing. Also it’s hard to follow the advice in POLICE if you’re rat-arsed!

 

Running or Re-injury through excessive exercise is sensible too. Healing tissue isn’t strong enough to manage the impact in running and is likely to breakdown causing further injury. You might think this would be fairly obvious but I have known runners to continue to run with alsorts of issues, including fractures!

 

Massage is also thought to increase bleeding and swelling, so I would avoid massaging directly over the injured area. A Physio may choose to massage distal to the swelling (further down the limb) to help reduce swelling, they may also massage to help acute low back pain so there are some exceptions.

 

This guidance comes from the New Zealand Guidelines Group and is available to download in full here.

 

As ever with injury the message from RunningPhysio is clear – if in doubt, get it checked out!

Sub-acute injury management

A lot of guidelines exist for management of acute injury. Most people will have heard of RICE, PRICE or, more recently POLICE. But what do you do when the acute phase ends? Continue with the ice? Stick your running shoes on and hit the road? This blog is to help you manage the next part, the sub-acute stage.

This advice is most useful for actual injury management, rather than a tight hamstring or a flare up of an old problem. As ever with this blog, it is not designed to replace medical advice – if in doubt get it checked out!

When does the sub-acute stage start?

There is no definitive timescale for healing as different things heal at different speeds but the sub-acute stage starts when the initial stage of swelling and pain has started to settle. There is usually a lot of bleeding in the first 6-8 hours post injury and a lot of inflammation for 2-3 days so the sub-acute stage usually starts between 3 and 7 days post injury and lasts until around 3-4 weeks.

What healing is taking place at this stage?

After the initial bleeding and inflammation your body starts the repair work. It does this by laying down new tissue usually in the form of collagen. This collagen starts off disorganised and “immature” and is not very good at managing load. If you place too much stress on this healing tissue it will breakdown and cause more swelling and pain. At around 3 weeks post injury the collagen has usually matured to a level where it is more efficient at dealing with some load but it takes 6-8 weeks to fully mature. Even beyond this stage tissue is being “remodelled” and strengthened further. Some structures will continue to heal in this way over a year after the initial injury. That said, we often consider things to be healed when they have reached a level where they can manage normal load and are without pain. Bone and muscle injuries take around 6-8 weeks to reach this level, ligament and tendon takes around 12 weeks. Areas with poor blood supply can be significantly longer.

What affect will the injury have on surrounding tissues?

Some injuries have immediately obvious effects. Injure a muscle and you would expect that muscle to be weak, but what if you injure a ligament or a bone? The resulting swelling and pain from an injury usually affect muscle strength, tissue flexibility, joint range of movement, balance and control of movement. An ankle ligament sprain, for example, usually causes a lot of swelling. The ankle joint stiffens as a result, the calf muscle may tighten, the muscles around the ankle become weak and it becomes very difficult to balance.

It is these issues that need to be addressed post injury to allow a problem free return to running. It often boils down to The Big Three movement control, range of movement and strength.

In the sub-acute stage you need to be guided by your pain, don’t push through pain and if you have specific instructions from your consultant or Physio stick to those.

Rehab of movement control

Part of movement control is something called “proprioception”, it’s how our bodies know the position of joints, muscles etc in space. It tends to be reduced after injury as described above. Movement control and proprioception work can be started as soon as comfortable after an injury, as it can be done very gently. Start with non-weightbearing exercises, this could be sitting with a ball under your foot, rolling it side to side, back and forwards, in circles etc or keeping a wobble board level (again in sitting). Some people do “alphabets” with their feet – drawing each letter of the alphabet in the air. A pool is a great place for balance exercise, bare in mind that if you are chest deep in water you reduce your weightbearing by about 80%. If it’s comfortable you could try single leg balance in the water, walking on your tip toes or heels and sideways walking. To gradually increase the amount of weight you take through an injured limb go progressively shallower in the pool. This is a great way to prepare for weightbearing work.

When comfortable you can progress to exercises in standing (out of the pool). You could start with 2 leg activities like gentle squats or wobble board balance and progress to single leg work balance work (detailed here). Use as much or as little support as you can manage, your aim is restore balance without causing pain or placing too much stress on healing tissue.

Restore range of movement

It’s important not to be overly aggressive in this area, find which movements are stiff and gently work into them. Common problem areas are ankle dorsiflexion (the upward movement), ankle inversion and eversion (turning the foot in and out) and knee flexion. Again, start in non weightbearing e.g. simply moving the foot up and down and in and out or bending and straightening the knee. You can try a static stretch as long as it’s comfortable, gradually build up towards a 30 second hold. When you feel ready progress to assisted stretching e.g. Using a towel or resistance band to add to the stretch, then add weight bearing stretches when able. Restoring range of movement isn’t just about stretching muscles, it’s about moving the joint. For example, simple squats and lunges can be very effective to loosen an ankle that’s stiff into dorsiflexion (I.e. won’t bend up) even though there may be little stretch on the calf muscles.

Restoring strength

Common muscles to be weak post injury are calf, quads, hamstring and glutes.

Try to gently work the muscles around the injured area as soon as it’s comfortable to do so. Start with isometric exercise. This means contracting the muscle without change in joint angle or muscle length. It’s a fairly static exercise so there is little stress on healing tissue, with the exception of the muscle you are working. One way to do this is to push against an immovable object, like a wall or the floor. You can even resist it with your good leg/arm. An isometric contraction can also be at the joint’s end of range where the joint itself prevents movement, for example static quads (sit on the bed with the leg straight and tighten the quads muscle). Muscle contraction also has the added benefit of improving swelling as it has a pumping action that helps move fluid from within the tissues. For other isometric exercises see the table below.

When comfortable you can progress from isometric strength work to working through range. Often it’s best to allow 7-10 days post injury to make this transition, after all, we need to allow the area to heal and there is little to gain in pushing things too quickly. Just the weight of the limb can offer enough resistance, e.g. with a straight leg raise exercise for quads. Body weight can also be used e.g. with squats or calf raises. Additional weights or resistance bands can be used if needed. It should remain pain free. Just work in whatever range is comfortable. Strength can also be gained by using equipment, like a static bike. Start with a low resistance and gradually increase. Keep movement comfortable and controlled.

How many, how often?

While the healing continues the priority is protecting that process, so if in doubt do less rather than more. Think of it as gently keeping things ticking over to prevent deconditioning (muscle weakness, joint stiffness etc.) rather than working hard to build strength. These exercises are best done little and often rather than all at once. I usually suggest that patients pick 3 or 4 exercises and do those about 3 times per day (morning, noon and evening) just doing as much as comfortable of each exercise. This might be as little as 4 or 5 reps. Which exercise you choose depends on what problems you are having following your injury. If you have no range of movement problems but feel very weak you would focus on strength work. If the muscles feel strong but the joints are stiff you would focus on improving range of movement. If strength and range are good but you struggle to balance you’d focus on that. Usually with injuries you’d also have guidance from a Physio or health professional on what exercises to do.

What else might help?

Ice remains useful as long as the area is continuing to swell. After 2-3 weeks if swelling remains you may want to replace ice with heat or contrast bathing. Both will improve the blood supply to the area to help clear swelling. Contrast bathing is using heat for 1 minute, then ice for 1 minute and continuing for 10-15 minutes finishing with heat. In theory this helps to cause blood and lymph vessels to dilate and then contract to pump fluid from the area.

Massage may help by reducing inflammation and pain, avoid aggressive painful massage around healing tissues. A compression bandage or supportive taping can also be used to manage swelling and support the area. Ultrasound may also help the healing process in soft tissues.

Closing thoughts

Gentle exercise can be used in the sub-acute stage following an injury but it should be done in a pain free manner with a gradual progression and respect to the healing structures. Loading tissues in this way can reduce deconditioning following an injury and help stimulate the healing process and development of collagen.

Injuries that create pain and swelling need to be assessed by your GP, Physio or health professional. Their guidance always supersedes that of general advice on this and other blogs.

Acute injury management – Woop Woop! That’s the sound of da POLICE!?

When it comes to managing an acute injury many of you will have heard of RICE and some will have seen it progress to PRICE. For those that missed it, it stands for;

 

  • Protect
  • Rest
  • Ice
  • Compression
  • Elevation

 

But a recent study by Bleakley, Glasgow and MacAuley 2012 in the British Journal of Sports Medicine has suggested this needs updating and in their words we “call the POLICE”. Aside from the obvious fact that the acronym now spells a word that can be used in mildly amusing blog titles (and awesome songs) it does make sense. So POLICE would be;

 

  • Protect
  • Optimal Loading
  • Ice
  • Compression
  • Elevation

 

So why replace rest with “optimal loading”?

 

  1. While rest may be helpful in the very short term, continued rest may lead to deconditioning of the tissues – joint stiffness, muscle weakness and tightness and reduced proprioception (control and balance)
  2. Optimal loading will stimulate the healing process as bone, tendon, ligament and muscle all require some loading to stimulate healing.
  3. The right amount of activity can help manage swelling. For example in the ankle, contraction of the calf muscles helps to move swelling up the body against gravity. Complete rest would the prevent this.

 

The key word here is optimal.

 

In some cases optimal loading may be no loading. Unstable fractures, complete tendon ruptures etc are unlikely to benefit from loading and may require casting, bracing or surgical repair. There is no recipe for this, each situation needs to be managed based on the person and their injury and usually under the guidance of a health professional.

 

Like so many things in health and injury it's about balance. I'm not suggesting you ditch your crutches and run off down the street! When it comes to managing acute injuries I recommend you seek medical advice, especially if there is noticeable swelling or any restriction in joint range of movement or a sensation of giving way. Bony tenderness or difficulty weightbearing are also signs that you should get checked out.

 

With acute injuries I see I tend to adopt a policy of weightbearing as tolerated. Meaning do as much as you feel comfortable to do and don't push through pain. This usually fits within the idea of optimal loading but as ever comes with the caveat, if in doubt, get it checked out. This also includes exercises, and I encourage people to gently move the joints around the affected area, again listening to the body and not pushing through pain. It's usually better to do this little and often to prevent stiffness rather than a lot at one sitting which is more likely to cause pain. Offload taping can also be very useful to support an area when you load it, for example the Achilles taping demonstrated in my tendonopathy post. For more on the affects of loading and exercise see this excellent (though quite technical) study by Khan and Scott 2009.

 

Ice

 

 

You might be surprised to hear that the research behind the use of ice is far from conclusive. There is a real lack of high quality evidence and very little guidance in terms of how ice should be used. Despite this we all tend to reach for the ice pack when nursing an injury and I think we are right to continue to do so.

 

Although the research may not be conclusive most of us have seen from personal experience that ice can reduce pain and swelling post injury and aid a quicker return to sport.

 

There area a few of safety points with ice;

 

  1. Don't ice over a numb area or open wound. If the skin is numb you won't notice if you're developing an ice burn and ice on an open wound would risk a infection
  2. Be wary of ice burns – don't apply ice directly to the skin, wrap an ice pack in a clean, damp tea towel before applying. Avoid prolonged exposure to ice, 10-20 minutes in usually adequate and also be careful applying the ice with too much pressure (e.g. Resting your leg on the ice bag).
  3. If you use frozen peas don't eat them after!

 

Practical details in the use of ice

 

Having read several reviews of the use of ice in the literature it's very hard to make an evidence based recommendation for use of ice in terms of how long to apply it and how frequently. There is some evidence that as little as 10 minutes can be effective to create tissue cooling and that, although fairly rare, ice burn can occur after just 20-30 minutes. Baring that in mind, and in the spirit of getting the most benefit with the smallest risk of harm I'd recommend the following very general guide;

 

Apply ice wrapped in a damp towel for 10-20 minutes 2-3 times per day for the first 5-7 days post injury.

 

Stop applying ice if there are any negative effects such as increase in pain or swelling or skin soreness.

 

I'll continue to look into the research for ice and cryotherapy and will update the post if i find any more specific recommendations. If you have a different method and it works for you, stick with it! Also worth noting is that cooling can be achieved using cooling gels if you prefer.

 

Compression

 

Similar to ice the research behind compression is far from conclusive. From personal experience I find compression very useful in managing swelling and it can be used in both the acute and more chronic stages. A simple tubigrip bandage can be used, especially good for ankles and knees and I tend to use 2 layers. The area should feel compressed but not uncomfortable or painful. Ensure there is good circulation distal to the bandage (I.e. in the toes if the ankle is compressed). I usually recommend patients to remove the bandage at night for comfort when sleeping and also because swelling is usually fairly well controlled when we are lying down.

 

Elevation

 

Elevation can be very effective in reducing swelling and pain. You can combine it with gentle exercises that aid circulation such as moving the ankle up and down or tightening the thigh muscles to straighten the knee. Obviously this will depend on your injury and the guidance you get from your health professional.

 

Hang on a mo….who's taken the P?

 

Yep I've forgotten to cover P for protection. Protection is part of optimal loading and involves the use of crutches, casts, braces etc to help protect the area as it heals. Think of it as a tool to prevent excessive loading in the early stages and it's especially useful if you are struggling to weightbear and need some extra help (in which case you need to make sure you've had your injury checked out).

 

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