Keep your shoulders and spine happy and strong by following Mike O’Hara’s advice in “Pushing Up Performance”. Video explanation and performance of pushups and their variations included. Jeff Tirrell discusses the proper performance of pull ups in his article. “Movement You Should Master”. Is your mobility limited? Try massage sticks or foam rollers with the information provided in “Pain, Pressure, and Pliability”.
How Do They Know What Is Wrong Without An MRI?
This is a fairly common question in physical therapy. Patients with lower back, leg, neck, and arm pain know the test they need is an MRI. They have friends and relatives that tell them they should have an MRI. They are concerned that something is being overlooked and that the pictures from the MRI will make treatment more beneficial. I have some research information on the limitations of a spinal MRI.
In 1994, the *New England Journal of Medicine published a study on physician evaluation of lumbar spine MRIs. The MRIs of 98 asymptomatic individuals –-no pain, feelin’ good people, were found to have disc abnormalities (82% of the MRIs).
-52% had a bulged disc at one level
-27% had a disc protrusion
-1% had a disc extrusion
-38% had an abnormality at more than one disc
Since that publication, several other studies have backed up these results. Bulged, protruding, and extruded lumbar discs are a fairly common finding on a lumbar MRI. Changes in our lumbar discs are probably no different than the wrinkles on your face or the gray in your hair. Changes in a disc’s shape is not a indicator of pain problems
Another **MRI study of athletes revealed spondylolysis (vertebral fractures) are fairly common, yet less than 50% of the athletes with these fractures ever report any episode of lower back pain. It appears that lumbar spine fractures do not always produce pain.
In my years in the physical therapy clinic, I have received the MRI reports of many neck and lower back pain patient’s spines that show disc protrusions and foraminal stenosis on one side of the spine but the patient has all of his or her symptoms on the opposite side. I have treated patients with severe lower back pain and completely normal spinal MRIs.
MRI research has demonstrated that “abnormalities” in our spines are fairly common and difficult to accurately link to any specific pain problem. We do know that once a patient has an MRI, they are far more likely to progress to ***surgery. Please read, The Myth of Accuracy in Diagnosis, by Dr. Ron Fudala. In physical therapy, the resolution of a spinal pain problem starts with a history and thorough physical evaluation. Imaging tests are a small part of the “big picture” and often provide nothing but confusion.
*Jensen MC et al. Magnetic resonance imaging of the lumbar spine in people with and without back pain, New Engl J Med. Jul 14
**Soler T, Calderon C. The prevalence of spondylolysis in the Spanish elite athlete. Am J Sports Med, 2000 Jan – Feb.
***Lurie JD, Birkmeyer NJ, Weinstein JN. Rates of advanced spinal imaging and spine surgery. Spine 2003;28:616 –20.
Michael S. O’Hara, PT, OCS, CSCS
Most shoulder pain problems are brought on by the cumulative effect of poor posture and weak scapula muscles. Sustained slouched over postures create a faulty length-tension relationship in the scapula muscles. This produces adverse stress and strain on the joints of the shoulder and the nerves in the neck and upper back.
The muscles that keep the shoulder healthy and pain-free attach to the scapula (shoulder blade). They hold the shoulder girdle in a mechanically advantageous position on the body. They pull the scapula inward, toward the spine and downward, toward the hips. Making your scapula muscles stronger will help, but being mindful of your posture during the day is the most important factor. I like the quote from Physical Therapist and US Soccer team trainer Sue Falsone “You can’t out rep poor posture.”
For the last two years, Janet had been “bothered” by lower back and hip pain. When the symptoms made walking and getting out of bed difficult, she sought medical attention. Janet had X-rays and Magnetic Resonance Imaging of her lumbar spine that showed she had some arthritis and stenosis in her lower back. She, then, underwent ablation of nerves in her lumbar spine and injections into her sacroiliac joints. These treatments decreased the pain in the lower back, but pain in the left hip and sacral region persisted. Three months after her last injections, Janet was referred for physical therapy.
On her initial physical therapy evaluation, Janet had none of the pain that caused her to seek medical attention. She stated the pain was present in the morning and with prolonged standing. She could stand for no more than ten minutes when the pain would become so intense she had to sit down. Sitting for fifteen to twenty minutes would resolve her pain. Janet had good spinal mobility, excellent hip range of motion, and normal strength in both legs. Her core stability was limited to a poor grade, but otherwise, she passed all functional tests. On further questioning about her lifestyle and activities, Janet failed a big test.
Janet: I walk on a treadmill every day.
Physical Therapist: How long do you walk?
Janet: One or two miles.
Physical Therapist: I thought standing caused you to have pain?
Janet: I do not have pain if I hold onto the rails.
Treatment: Stop walking on the treadmill.
Janet was skeptical. After all, walking was good exercise, and she wasn’t in pain if she held the rails. How could something good for you perpetuate the pain? Janet, however, was willing to try anything to get rid of her pain, so she agreed to a one week break from the treadmill. Ten days later Janet was pain- free.
When you walk on a treadmill you perform 2,000-2,500 step repetitions per mile. With every step taken, you must decelerate and then accelerate one and a half to two times your body weight. Holding onto the rails or the console of the treadmill can easily add 10-15% more load through your spine and pelvis. A woman who weighs 135 pounds walks with a fifteen pound weight vest on her back when she holds onto the treadmill. Torso and pelvic girdle rotation is a key component of normal locomotion–watch any speed walker. Holding onto the rails restricts the free flowing, rotational component of gait. Thousands of repetitions of a restricted gait pattern, with extra load, performed on a daily basis, can create lots of pain problems.
Treadmill gripping is a common driver of pain problems. As is often the case, the pain is not experienced during the treadmill exercise session, so the patient does not connect the activity with the symptoms. Patients with head, neck, lower back, and leg pain symptoms often have this same well-intentioned exercise habit.
-Michael O’Hara, P.T., OCS, CSCS