Beliefs about how pain is experienced and interpreted are key to managing conditions in people who have long term pain. Arguably introducing musculoskeletal pain sufferers to the concepts inherent in something called Cognitive Behavioral Therapy or CBT could help people cope so much better with the burden of putting up with chronic discomfort.

Sufferers need a broad approach to enable them to help themselves and understanding some of the concepts behind how we experience pain is thought to be helpful and to my mind makes perfect common sense.

An excellent article in an Occupational Therapist’s blog called Health Skills puts it far better than I in article written here.

Two points I found that resonated well  are that essentially pain is a personal experience, different from one person to another and therefore that has implications for its management.

The second is that there are definite neurological mechanisms that help to explain why someone in long term discomfort has a  sensitive nervous system that can be easily influenced by lots of things and sharing this with sufferers is helpful.

For back pain sufferers who have repeated episodes I think it is really important to introduce them to some of these concepts early so that the chances of the cycle of chronic pain is not triggered.

CBT is available locally in some  GP practices, the back pain pathway and also at the Pain Clinic but it is important that anyone in the business of caring for those in pain understand its concepts are ready to encourage people to look at pain as something that can be lived with and accepted and that it need not define them.

Easy to say and very much more difficult to do.

I regularly see patients who, when they lie down, will appear to have one leg significantly shorter than the other. This is called leg length alignment asymmetry  (LLAA) or apparent leg length Inequality  (LLI) in the trade. This should not be confused with actual or anatomic leg length Inequality. Confused? I’m not surprised.

The Gold Standard to measure actual leg length is an x-ray and when applied to the normal population ie the first 100 or so folks you meet coming out of the supermarket, you will find that there is some discrepancy between the actual size of the legs in about 90% of us . That’s a whopping number. In fact it is quite rare to have legs that are the same length. However this difference is mostly small – estimated to be an average of 5mm.

Of the 90 % of us with uneven leg length, less than 5% will have what could be considered to be significant anatomic LLI of over 20 mm. In other words folks who have a longer leg on one side by at least 20 mm could possibly be suffering back pain, knee pain, hip pain and also have a terrible predilection for getting lost in deserts.

In fact it is quite rare to have legs that are the same length.

As we said earlier that there is an anatomic LLI and an apparent LLI; what’s the difference? Well, the apparent LLI is caused by tight muscles that attach to the pelvis principally the Quadratus Lumborum or QL. The QL attaches to the spine above and to the pelvis below and will hoik up the pelvis on one side if it is tight. It is this hypertonicity which causes much apparent LLI.

When there is an actual shortness of one leg of less than 20 mm the body does a neat little trick and compensates with some tight muscles but this does not usually cause any problems.

So don’t be too worried if you are told you have one leg shorter that the other – most people do. It is extremely unlikely to be the cause of any problems unless the difference is more than 20 mm. And in that case make sure you take a compass with you the next time you go for a walk in the Sahara.

Some of my patients on learning that I spend my Sunday mornings in an offshore rowing boat  get quite animated as I have often advised them that rowing  can only lead to a lifetime of pain. I exaggerate, however I have made the observation that rowing leads to back pain especially in those who already suffer.

So what exactly is the problem with rowing when it comes to the back. The most common injury among healthy rowers is low back pain and remember most people who row are young and fit.

In an article written for the British Sports Journal, D Reid postulates that there are a variety of causes of back pain in rowers beginning with the obvious; the action of rowing involves bending forward and, through the sitting posture, compression. The spine doesn’t do flexion and compression repeatedly as the outer rim of the discs tend to tear creating  a bulge or a so called “slipped disc.”

Mr Reid also suggests that morning time training is a problem. It has been know for a long time that the intervertebral disc absorbs tissue fluid overnight  and is therefore less elastic in the early hours of the morning or at least before the extra fluid is squished out of the disc with the repeated pressure of loading. It is estimated that the bending stresses on the back is 3 times more in the morning.

So we have seated flexion and early morning rises, what about the rowers themselves? Well as with most back pain, strength or lack of it is no predictor of back pain but rather it is the lack of stamina. With long sessions fatigue sets in, the core muscles loose their ability to regulate and adapt movement and less benign motion patterns set in. There is also the question of the repeated cycle of flexion of the spine and rather like a paper clip being continually flexed and extended this weakens the holding elements of the spine.

Short hamstrings prevent the full movement of the pelvis and therefore the lumbar spine which can lead to poor posture and little resistance to stresses of rowing.

We see therefore a number of problems that can be easily associated with the high incidence of back pain in rowers so why am I exposing myself to such risk? Well, two reasons ; firstly it is support my son in his hobby and secondly I can, I think, mitigate some of the worst affects of rowing by understanding the biomechanics, building my core muscles and making sure I warm up properly before I get on the water in the morning.

I still advise people with back pain not to row and for those without back pain , know what you are doing and don’t get too tired.

Many GPs regard thoracic onset as a so called Red Flag symptom ie one which would heighten your index of suspicion that there may be a process other than mechanical back pain going on. These other conditions may be osteoporosis,  osteomyelitis (infection of one of the vertebra,) TB and even secondary  or primary cancer. There you go, now I have gone and scared everyone!

Suffice it to say that most thoracic back pain is the result of a problem with the joints of the back or of the ribs that insert into the back joints in the thoracic spine. Is is very rare for there to be other causes like those mentioned above.

The key to managing these conditions is firstly a decent diagnosis, and in some (first episode in those over 55 years, deep throbbing night pain, history of other related pathologies) that may mean an xray. If , as is most probable, a diagnosis of mechanical pain is made then firstly keep moving. Secondly if it is persistent ( more than a week) have some deep tissue massage and manipulation. It shouldn’t take more than a week or two for it to resolve.

I have a number of patients who have had repeated episodes of thoracic pain and we manage them with regular massage, exercise and manipulation. Some of these folks have had Scheuermanns Disease ( a generally self-limiting condition) as teenagers which can often lead to some degenerative changes in the thoracic spine. Some have a minor curvature in the spine which leads to asymmetrical load bearing on the spine and can produce discomfort.

The message to take away is that most thoracic pain is easily remedied with simple measures but it needs to be taken seriously.

So what do I do. Well evidentially I could opt for one of two paths; firstly I could rush to my GP and ask to have it injected with cortisone. There is a good body evidence that cortisone will help with the pain – in the short term. After about six weeks the effect will wear off. The other route is to do the sorts of things that I do to other people i.e. soft tissue work, dry needling, ultrasound and manipulation. This has been shown to be slower in reducing the pain but provides a better long term answer. I have noticed this in my practice; patients who have had cortisone, sometimes up to three times, seem to do worse with the conservative approach in the long run.

Of course failing all that, there is an operative solution to be considered which usually involves debriding the extensor tendon and sometimes releasing the capsule and seems to have a relatively decent hit rate. There is however not much information about whether surgery is better than anything else including leaving well alone.

So what’s causing my tennis elbow or lateral epicondylitis as it is more properly known? My best guess is that, as with so many musculoskeletal problems, there are multiple factors involved –  two primarily. Firstly I fell off my bike a few months ago and have suffered some minor neck and shoulder pain since. Physician heal thyself you say and quite right too! Secondly the last year of cycling has meant a considerable amount of extension of the wrist and tight gripping in that limb. I need to change my bike handle bar, get my neck and shoulder fixed and then treat my elbow with soft tissue work, acupuncture and manipulation of the elbow and wrist. I’ll report in but I expect my elbow to resolve in a week or two.

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I have tried many different rubs and ointments but this one has been persistently rated by my patients. Like all applications it is by no means a panacea but people consistently rate its effect on their musculoskeletal pain.

Having tried many different types of Lumbar Supports for our patients this one has stood the test of time.

* New
* Size – to fit waist 28 – 34 inch ( See other listings for other sizes)
* Flexible but strong
* Supportive but not too restrictive
* Doesn’t get too hot
* Easy to put on
* Four posterior flexible stays that provide as tight a fit as you want.

There is not much evidence that Lumbar Support Belts provide any lasting relief for back pain however in my experience they are really useful in keeping the back stable during periods of acute pain or during repetitive physical work like gardening. I keep mine in the tool box so that when I am thinking about lifting something awkward it is there to hand. Belts don’t really help if worn all the time. They will tend to encourage ‘deconditioning.’ They provide that extra little bit of support when your back is painful or vulnerable rather than an answer to long term low back pain.

Fat or Fit?

There is very little strong evidence of a firm link between loving your doughnuts and getting back pain. Too many patients tell me that their Doctor has told them to lose weight and their back pain will disappear. It is used as an excuse sometimes to avoid confronting what for most GP’s is a heart sink problem;

“If only the patient would loose a bit of weight then they would stop asking me for advice for a condition I cant do a thing about!”

There is no doubt that being overweight is health issue and of course extra weight is going to put more force through weight bearing joints like knees and hips. However, there is no really good evidence though that there is a causal relationship between weight gain and back pain. In my opinion it is more about fitness than weight. Back sufferers who do a little exercise feel better. Fitter people are also usually a little thinner.

Not only that but the stabilizing muscles of the back if worked regularly are commonly thought to keep back pain at bay. There is no doubt that for most back pain sufferers, keeping fit will substantially reduce their discomfort.

So if you are on a crash diet for your back pain I wouldn’t bother; get fit instead. That way you will probably lose your back pain AND a few pounds as well.

Keith Walker, a chiropractor in England, is already using the tool in his clinic. And so far, it’s been a hit.

“As a patient education tool, it’s one of the best I’ve seen,” he said. “There are other things like this on the Web, and they tend to be not as usable, or on medical university Web sites and directed at students.”

Mr. Walker wishes that the 3-D model had limbs that rotated. For example, users can’t lift the wrists of the model, which happen to block a portion of the hip.

The browser also lacks the sort of detail a serious student would need, he said. “If you look at the shoulder, you can’t peel off the layers,” he said. “There are some really important muscles under the deltoid, and you can’t see those.”

Read the rest of the article on the New York Times website