GENERAL GUIDELINES FOR LOOKING AFTER YOUR BACK

Low back pain is an extremely common complaint, not just with patients presenting to Physio Noosa but in the community as a whole.  Over 85-90% of us will have some degree of back pain at some stage in our lives.  For 90% of people affected, resolution will occur within 3 months.  But this is not the case for nearly 50%, as they will have at least one recurrent episode (Brukner and Khan, 2007)  Back pain is the most common complaint for people under the age of 45 years of age and causes significant loss of time at work and carries huge economic burden.  The cost of low back pain in Australia is over $9billion (Walker, Muller and Grant 2003)               

With this is mind, here are some tips on how to reduce or even prevent episode of back pain.

Limited sustained postures:  Vary positions.  This reduces the static loading that is placed though the spine when a task is either all sitting or all standing and assists in postural muscle activation.  Consider a stand-up desk option for work so sitting times can be reduced and postural variation can occur.

Exercise:  In general, get moving.  Improve and then maintain overall levels of fitness.  Start easy; aim for consistency; develop routine with simple load bearing activity such as walking.  Commence specific Physiotherapist guided exercises to improve spinal range of motion, strength and stability and implement these into your daily exercise routine.  You need to exercise every day for ‘exercise sake’.  Being active each day is important, but doesn’t take the place of exercise.  Remember what you do and how you do it is paramount.  Think about your lifting technique prior to loading (Is my spine straight? is my core engaged? Is the load too heavy? Do I need assistance?)

 

Posture:  Ensure ideal postural positions when sitting, standing and moving.  Make sure your posture is ideal prior to any lifting, carrying, pushing or pulling activities; no matter how light the task may seem.  Ideal posture will reduce the load and the mechanical forces acting throughout the spine and therefore prevent injuries. 

Improve overall health:  Do an honest assessment of your overall health.  With the abundance of information and education available to us in this digital age, it is easy to know where we are falling behind in areas of nutrition, hydration and general health care.  Make small changes each day to these areas and you’ll notice the difference in your health and wellbeing in no time.  Consider wholefood, plant based nutrition.  Reduce intake of animal products and ensure those consumed are the best quality you can afford.  Stop smoking.  Reduce alcohol intake to levels recommended by www.alcohol.gov.au and increase intake of clean, clear fluids. 

Risk factors to consider according to Bruker and Khan (2007)

Risk Factor	Evidence
Age	Inc risk until age 50, then relative risk decreases in men and increases in women
Gender	Multiparous (more than one pregnancy) women, three times the risk
Obesity	Unclear
Height	Unclear
Posture	No association with lordosis or leg length discrepancy
Smoking	Strong association with low back pain and sciatica
Physical Work	Inc risk in those whose work involves bending, twisting or heavy physical labour.  Inc risk of low back pain and sciatica with exposure to vibration Coal miners have fewer disc protrusions than other occupations Low risk of low back pain in farmers
Sedentary Occupations	Inc risk when seated Driving a car may cause LBP or disc herniation Jobs involving all standing or all sitting show higher incidence of LBP than those with changing positions
Increased Fitness	Some evidence that good isometric endurance of back muscles may be associated with reduced LBP
Psychological Factors	Stress, anxiety, depression associated with work related LBP

Remember, if you are experiencing spinal pain or have concerns relating to any of the above, visit us at Physio Noosa where our team will provide specific assessment, directed treatment and an individualised exercise program to suit your needs.

www.physionoosa.com

This is posted as a general guide for people with non specific mechanical low back pain.  Should you not be certain as to what type of back pain you have, please see your health care professional for an assessment and diagnosis prior to commencing any of the above.

References:

Walker BF, Muller R and Grant WD  (2003)  Low back pain in Australian adults: the economic burden.  Asia Pacfic Journal of Public Health. 15(2)  pp79-87

Brukner, P and Khan K (2007) Clincal Sports Medicine 3^rd Edition. McGraw-Hill, Sydney

WHAT HAPPENS IN AN ACUTE LIGAMENT SPRAIN AND HOW CAN I MANAGE IT?

In our Physiotherapy practice (www.physionoosa.com.au) we get asked many questions, but this is one that has been at the top of the list this week; perhaps because training and competing for many sports is well under way and the inevitable injuries result.  So, one our Physiotherapists, Ross Drummond has penned some thoughts on ligament sprains.


When we expose our joints to extreme force beyond which our muscular and neurological systems can handle, increased tension and stretch to a ligament can cause it to tear or rupture.  The following grades of ligament sprains are:

Image from Brukner and Khan, Clinical Sports Medicine
2007

Grade 1 - mild:  stretched fibres, some micro tears, normal joint integrity and movement
Grade 2 - stretching and resultant tears to many fibres of the ligament with joint and ligament laxity present but a defined end-point noted on testing
Grade 3 - complete tear of the ligament with excessive joint laxity with no defined end -point noted on testing  (Brukner and Khan 2007)

Once the injury occurs the area will go through the following phases of inflammation called the 'inflammatory cascade'.  This ensures the ligament heals in the best was possible and will typically display the following 5 cardinal signs of inflammation:
1. Rubor (redness)
2. Calor (heat)
3. Tumor (swelling)
4. Dolor (pain)
5. Functiolaesa (Loss of function)

Inflammatory Phase:
This phase commences following the acute trauma to the ligament and can typically last anywhere between 3-5 days.  When the tissue cells become damaged they stimulate the release of  various chemicals and inflammatory mediators that initiate the inflammatory response.  These chemicals include prostaglandin, bradykinins and histamine.  They work together to increase blood flow to the site of injury through vasodilation and increased permeability of the tissues.  These chemicals elicit a pain response and pressure from the swelling onto local nerves increases the pain we feel.  The main objective of inflammation is to target and eradicate the irritant and repair the damaged tissues.   Rehabilitation in the early phases (initial 24hrs) of injury can greatly improve recovery. This consists of protecting the injured area to be protected from further damage by immobilisation and minimal weight bearing of the injured joint, rest from activities that will involve the injured body part and by using ice, compression and elevation (RICE).

Brukner and Khan flow chart 

Repair Phase:
The second phase of inflammation is mediated by blood clotting over the damaged tissue cells.  At this time, blood platelets form a mesh to initiate healing.  Within the blood clotting mechanism, fibroblast cells commence the lay down of immature collagen tissue which typically occurs between 3 and 21 days post injury or trauma.  During this stage of healing, electrotherapy such as ultrasound has been shown to encourage fibroblast activity which encourages a structurally stronger ligament.  Physio guided rehabilitation assists in facilitating better alignment of collagen and elastin fibres thereby reducing adhesions and scarring.

Remodelling Phase:
This phase follows the repair phase and can last for up to a year depending on the severity of the damage.  This phase involves the maturation land realignment of collagen tissue fibres.  When first laid down, collagen tissue is disorganised and therefore doesn't possess a great amount of tensile strength.  Through the gradual introduction of controlled strain in the ligament's plane of motion, the ligament gradually strengthens and realigns fibres in a longitudinal manner.  This controlled strain can be facilitated through controlled exercises that progress to functional activity,  Physiotherapist directed exercise programs will safely assist the final process of remodelling and aid recovery.  The risk for re-injury during this phase can be reduced by providing additional support to the joint and ligament with strapping, strength training of muscles in surrounding areas and performing proprioceptive exercises to improve joint positioning sense.

Remember, Physiotherapy guidance is important to facilitate healing and obtain full movement capacity and there is only a very short window of recovery.  If you delay treatment for your injury now then you may prolong time off training, reduce competition ability and performance and increase your chance of re-injury.


   "An ounce of prevention is worth a pound of cure" 
Quote by some wise old person named Benjamin Franklin.


References:

Brukner, P and Khan K (2007)  Clinical Sports Medicine. 3rd Edn.  McGraw Hill Medical. Sydney

Martini, FH & nath, J (2008) Fundamentals of Anatomy and Physiology. 8th Edn.  Benjamin-Cummings, CA

Wolf et al (2013) Treatment of acute ankle ligament injuries: a systematic review. Archives of Orthopaedic and Trauma Surgery. Vol 133, No 8, pp: 1129-1141

HOW BEST TO OPTIMISE YOUR TRAINING

Well, it has been a long time between posts and something I plan on rectifying.  Someone once said to me that we all make time for the things we want to do!

A question I get asked a lot in clinical practice is “How do I get the best out of my training in order to achieve my goals?” or words to that effect.  So I thought I would attempt to shed some light on the topic of “training optimisation” especially given the endurance trail running season is upon us.  So I have penned some thoughts with long distance trail running in mind, however the principles can be applied to other distance and other sports.  Here are some variables to take into consideration.

DISTANCE

www.nutrs.com.au  best running group around!

How long is the event and how should I go about preparing for it?  A general rule of thumb is to aim to cover the distance of the event in one week’s worth of training.  Ie:  100km race; reach 100km of training the week approximately 3-4weeks out from race day.  Periodisation of training needs to implemented in order to gradually build to these levels without succumbing to injury or illness.  For example:  use 4 week cycles to build up distance and time on your feet progressively over 3 weeks, followed by a recovery week similar in distance/time to the initial 1^st or 2^nd week of that macro cycle.  Start conservatively, build gradually and hasten slowly. 

TIME ON FEET

How long will the event take me to complete?  Aim to spend up to 50% of this time on your feet in training in one session at a pace slower than what you will be competing at.  This allows for hydration and nutrition plans to be tried and tested, develops mental toughness and preparedness and allows for the musculoskeletal system to harden and adapt to training.  This needs to be at sub-threshold levels….long, slow and steady conversational pace.  This pace is important so that the system isn’t stressed or over-reached.  Allow time for recovery before the next session and ensure that the next training session isn't hard or fast.  

PACE

Take the time to enjoy and breathe!

Ensure that your training program adequately trains the aerobic system.  This can’t be stressed enough.  This is the foundation upon which the all physiological systems of the body depend upon for long distance events.  Long, slow, sub-threshold training should be the cornerstone of your training.  Once a solid grounded base has been achieved over at least 8 weeks (at least 2 macro-cycles) only then should specific higher heart-rate sessions be included and only then for sessions strategically positioned into the training program.  This allows for adequate time to recover from harder sessions and prevent any injuries.

TERRAIN

Local Noosa Trails

What type of surface/terrain will I be running on? Technical single track, wide fire trail, mountain goat ascents/descents, road, stairs.   Attempt to mimic this in training as much as possible in order to prepare the legs for what will be required.  If a large portion of the course is technical, then this requires a specific skill set that needs to be trained prior to event day.

TOTAL ASCENT/DESCENT

Mt Solitary in the Blue Mountains is a popular training ground 

If your event has 4000m of ascent gain over 100km, then training needs to simulate this; e.g: broken down into 400m+ of ascent over 10km.  Practice different methods of ascent to mimic your climbing of these ascents during your race.  How you ascend and desend early on will vary later on in an event when you are tired and fatigued.  This is particularly important for ultra-events where power-hiking steep uphills will be required and often this is something we often don’t practice enough in training.

ENVIRONMENTAL CONDITIONS

Aim to train in environmental conditions similar to race day.  Often this is not possible when travelling interstate/internationally, so aim for training in the coolest/warmest parts of the day to simulate your race environment.  Be prepared with your hydration, nutrition and electrolyte needs ahead of time.  Also plan to arrive in your race destination with plenty of time to acclimatise.  A general rule of thumb for events at elevation is to allow at least 1 day for every 1000ft of elevation above sea level.  Expose yourself to the elements on arrival in your race destination and allow the body to adjust.  You need to get out and move in the new environmental conditions and not just sit at the nearest café!  This assists with acclimatization physiologically but also allows you to test the adequacy of any gear specifically required for an event in a unique environment.

RECOVERY

“One can not underestimate the power of rest”. This probably deserves blog of its own.  Recovery should be the cornerstone of every training program.  Physiological changes and adaptations to training can only occur when the body is allowed to rest.  Recovery and rest can take different forms and there is a large body of evidence to support active recovery such as: light aerobic activity different to that usually trained.  Recovery also is largely influenced by nutrition and hydration strategies, musculoskeletal strategies (physiotherapy, massage, acupuncture etc) and sleep! Finding the right combination for you is as much and art as it is science.

So, there are some areas to consider when planning your training program for your upcoming event.  

Enjoy those trails, enjoy your training and remember "Mistakes are proof you are trying" Anon

TNF100 2014

Summer training with B-Dog

Well….it has been sometime since I last posted….life gets busy with all the usual things, especially when you add in preparing for an ultra-marathon!  My plan for this year was to run the 50km event at TNF with my cyclist husband.  As it would happen, he became quite unwell and hadn't been able to train at all and the best option would be to sell his entry.  I decided that if he wasn't going to do the 50km then I would transfer up to the 100km now that there was a chief cook, strapper and babysitter available!!

My training had been on track with decent progressions in distance and elevation with only some minor 'niggles' to nurse along…until….2-3 weeks prior to the event I tripped over an inconsequential tree root whilst running home in the dark (yes.i did have a headlamp on!).  Whilst there was some initial discomfort, I was able to run another 5km home.  A couple of days later, running was not at all possible.  Anterior knee pain pulled me up.  Usual treatment ensued with not much change in my ability to train…..in fact, no running at all.  I had some diagnostics performed at short notice (fortunately my local radiologist is also an ultra-runner!) Results were encouraging, showing only grade 1 patellar tendon strain and mild infrapatella bursitis.  I continued treatment and resumed light training, but still had a lot of pain on running…not all that encouraging when about a week out from race day :Z

Another round of treatment 

In the week leading up to race day I did a lot of walking, hiking and shorter jogs in the Blue Mountains to test the legs.  I started to feel more confident in actually standing on the start line by the Thursday before.  I had spent some time contemplating whether to start. I didn't want to be a liability to the race organisers nor any of their staff by getting myself into a situation that I couldn't safely get out of, nor compromise anyone else's safety for that matter.   Having done this event 4 times previously, I knew the course well.  I decided that I would give it a go and mitigate any risk, take one checkpoint at a time and remain in phone contact.

Lucky 537 :(

Decision made…..race day arrives and off I go in wave 4.  Quite tentative and easy to keep the load on the legs nice and light.  Bitumen section completed and down Furber stairs we go.  Legs feeling relatively good.  I clamber over the landslide and make my way around to Golden Stairs whilst trying hard to reign in my forward motion! Up Golden I go and I make a point of staying behind some slower less confident runners.  It was good to keep my breathing contained but frustrating at working at an uncomfortable pace.   I went through CP1 feeling great…I felt really good metabolically.  no nausea,

At race start in my PJ's to keep the sore legs warm!

no vomitting, no shrek hands, no cramps like last year.…YAY!! .My hamstring had started to tighten somewhat but in true Physio fashion I ignored it….or at least tried to.  Fast forward 10km along Narrowneck….patellar tendon/hamstring/adductor not happy at all…..then….nek minit….bang….there goes the hamstring in a big way.  There is no ignoring things now…..can't run, can't walk.  I spent some time weighing up my options and attempting some form of self treatment but to no avail.

There is never a time where there is an easy decision in climbing into the 'Wagon of Shame', getting transported back to race base and signing the paperwork to withdraw.  It is a hard pill to swallow after all the hours, the miles, the early starts hours before the sun rise, the missed social occasions and all the other sacrifices that are made not only by me but also my family in helping me achieve my goals.  It is never easy….for anyone.  I was devastated and very disappointed in falling way short of my expectations and I only held it together until my amazing, wonderful family met me in the medical tent with kisses, cuddles and a beautiful bunch of flowers.  I felt so undeserving, so humiliated and so unworthy of anything.  But there they

Flowers from my amazing family xx

were….holding me and soothing away all of the negative feelings and putting things into perspective…..that standing on the starting line willing to give it a go was the most important thing for my children to see.  This was my moment of clarity.  Be strong, stand tall and get back out there.

Guy Holloway getting butt rub!

So, I got changed, bandaged a bunch of ice packs to my leg and off we limped to the checkpoints.   I had a lot of friends competing and wanted to cheer them on and support them in any way I could.  We followed them from CP 3,4,5 until nearly 12am!  What an inspiration they were……Guy Holloway and Frank Falappi…you both were hero's of the day.  Thank you for letting me be part of your journey…..you both bought tears to my eyes on more than one occasion (and not just when I had to put my hands down your pants Guy and trigger point your butt!!).  Ian Rowe….for a TNF virgin…you handled yourself like a pro!  Fantastic effort!  Adam Connor….you are an amazing competitor and you give so much to so many people. You set the standard for all trail runners.  Marina Brun-Smits….you are the most
admirable lady and you set the bar for what I aspire to.  Thank you for the beautiful hugs along the way.  Andy Bowen….what a checkpoint, grim sweeper leader!!  There are many people who owe their completion to you…you are one mean negotiator!!

Grim Sweeper Andy Bowen! What a sight!!

Although my run didn't go to plan, I am forever grateful that I could be part of the TNF journey for so many people.  Sometimes we need a change in focus to gain perspective on the important things. Now…to plan for the next one!

POST EVENT RECOVERY

2 weeks after the event that was TNF100, I've had some time to reflect on what worked and what worked didn't.  But instead of  lamenting over the 'what-ifs',  I've been focusing on how to best facilitate my recovery.  

After having several days of feeling very much below par,  I had some blood tests and a general check up performed five days post race.  At this stage I was concerned about my kidney function as I was still more than 5% above my race starting weight and had notable peripheral oedema. I also had investigations into gastric ulceration as race day nausea and reflux hadn't settled.  As an athlete and a Health Professional, I am acutely aware of the impact of ibuprofen on kidney/renal function and gastric ulceration and refuse to take anything in the NSAID family of pharmaceuticals pre/during/post race or at all.  Another consideration is that paracetamol metabolism is undertaken primarily in the liver, so I also avoid this group of drugs as well.

General systemic check showed normal BP for me (110/50) and HR 55 with normal rhythm.  During the event I had several episodes of SVT (HR: 180) that lasted for around a minute and gradually reduced with a gentle carotid rub, so a normal rate and rhythm was good news.   The results of my blood tests came back with surprising results.  All electrolytes, vitamin D and B6/B12 (specifically), calcium and iron levels were normal (good news considering a near vegan diet!).  Kidney function was normal and in fact, optimal.  No evidence of gastric ulceration either. The outliers were my liver enzymes, with nearly all being elevated above normal.  

I've done some empirical and anecdotal research since being given these results and have found elevated LFT's seem to be present in some athletes following long distance events and also after high intensity events.  The liver seems to be bombarded with toxic by-products of extreme exercise such as skeletal muscle breakdown (rhabdomyolysis) and lactic acid and is unable to process and metabolise these toxins effectively.  Not only is the liver trying to keep processing and suppling energy to the working muscle, it also having to deal with becoming loaded with toxic by-products.  The end result is liver dysfunction. (most notable causes of liver enzyme dysfunction is infection, obstruction, cirrhosis, fatty infiltration, myocardial stress, medication use, alcohol abuse and skeletal muscle trauma).  So, given this, the most likely culprit is racing induced muscle trauma.  

The Liver: time to pay more attention to this vital organ

However, I, along with over 30% of surveyed TNF2013 respondents (www.ultra168.com) used Hammer nutrition as their primary source of race day nutrition.  I was one of those respondents.  These products worked well in training with my GIT tolerating them very well.  Race day was another story though!!  On searching the USA Hammer Nutrition website, a marathon athlete posted having raised LTF's post event and thought that there may have been a link to the products being used.  He ceased the Hammer products, had bloods performed and his LFT's returned to normal levels.  As a trial he recommenced the products and had further blood tests performed and ....voila....a return to elevated LFT levels.  Co-incidence? Maybe.  Admittedly, one case does not mean the results are the same as a double-blind ramdomised controlled trial.  But in my case....definitely food for thought.

Specific recommendations for liver recovery:

• No alcohol 
• Review/cessation of  medicines, supplements
• Nutrition for optimal liver function: broccoli, kale, apples, beets, garlic, cauliflower
• Specific liver herb: milk thistle
• Low grade, low level exercise only:  so as to not cause skeletal muscle trauma (I did see that the recommendation by Hammer Nutrition was for 6 weeks complete rest for the above mentioned athlete and then re-test)...that length of rest is probably not going to happen in my case :-P
• implement the above and see what the repeat bloods show.

Lessons Learned:

• Listen to what your body is telling you during racing...it won't the same as in training
• Act early in making changes to hydration, nutrition, pace and nervousness levels
• Don't persist with what's not working
• Have more fun with running!!
• Hindsight is a wonderful thing!!!

Mummy and Maddi being bears in the woods at a local running event!

“Struggling and suffering are the essence of a life worth living. If you're not pushing yourself beyond the comfort zone, if you're not demanding more from yourself - expanding and learning as you go - you're choosing a numb existence. You're denying yourself an extraordinary trip.” 
― Dean Karnazes, Ultramarathon Man: Confessions of an All-Night Runner