Monthly ArchiveNovember 2008



Writer's Block 30 Nov 2008 06:55 pm

Writer’s Block Nov 30

Nov. 26, 2008

Back Pain and Lifting Belts

Once upon a time it was commonly believed that wearing a lifting belt would prevent back injury. You couldn’t go to a gym or health club and not see dozens of weightlifters and bodybuilders wearing them. I even have one around here somewhere.

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All that has changed now. The last time I was at the gym, I don’t recall seeing a single belt anywhere in sight.

So, does that mean they don’t work? Or that wearing one is a bad idea if you’re dealing with back problems?

That’s a good question. I stopped wearing mine because I had a hunch that it was more a liability than an asset — and it appears that most of the other lifters are of the same opinion.

But hunches and opinions are just hunches and opinions. Everybody has one and they aren’t worth much.

The only way to actually separate the facts from the folklore is to turn to those guys with the white lab coats (and way too much time on their hands) and see what they’ve been up to lately.

Here is a rundown of the latest findings:

First up, is a study published just this year (2008) by the Musculoskeletal Disorders Group at the Finnish Institute of Occupational Health in Helsinki, Finland. They concluded:

“There is no evidence to support use of … lifting equipment for preventing back pain or consequent disability.” [1]

Notice that they didn’t say that wearing a lifting belt was bad for you, only that there was no evidence to suggest that you need to wear one.

Next, we have a study conducted by the Institute for Work and Health, Toronto, Ontario, Canada. Their findings…

“Currently, because of conflicting evidence and the absence of high-quality trials, there is no conclusive evidence to support back belt use… ” [2]

Sort of reminds me of an old Herman’s Hermits song… “Second verse, same as the first.”

Herman's Hermits

Undaunted we move back over the pond to Amsterdam and the folks at the Institute for Research in Extramural Medicine who had this to say…

“There was moderate evidence that lumbar supports are not effective for primary prevention. No evidence was found on the effectiveness of lumbar supports for secondary prevention… There continues to be a need for high quality randomized trials on the effectiveness of lumbar supports.” [3]

Wait a minute…

“There continues to be a need for high quality randomized trials?”

So what exactly is it we’re paying you guys to do? Sorry, just kidding. I know you’ve been tied up lately, what with the kids and everything…

(I swear. You ever get the feeling some of these guys are just phoning it in?)

Speaking of which, here’s a summarization of the prevailing literature by the hardworking crew at the National Institute for Occupational Safety and Health (NIOSH) that further echoes the above opinions…

“They (back belts) appear to have little effect on most back injury risk factors, but may have a limited effect on improving muscle strength and supporting the back during lifting and twisting activities… Based on insufficient objective scientific data, NIOSH recommended against back belt use by healthy people.” [4]

Anyone else starting to notice a pattern here?

Anyway, moving right along, the Program in Physical Therapy at Washington University School of Medicine reports.

“The epidemiological data concerning the efficacy of back belts in the prevention of occupational low back injuries are not sufficient to warrant general use of back belts in the occupational setting for uninjured workers.” [5]

They then go on to add…

“There is actually a potential for increasing the degree of low back injury with general application of back belts in occupational settings.” [5]

Finally, we have at least some indication that wearing a back belt may actually weaken the spine and set you up for injury at a latter date. Nothing conclusive, mind you, but they seem to be thinking along the same lines as the rest of us.

Arbys

“In sum, there are insufficient data in the scientific literature to indicate that general use of back belts in occupational settings is appropriate for uninjured workers.” [5]

At this point, I’m thinking Arby’s, but let’s look at one more, then we’ll wrap this up.

“In the largest prospective cohort study of back belt use, adjusted for multiple individual risk factors, neither frequent back belt use nor a store policy that required belt use was associated with reduced incidence of back injury claims or low back pain.” [6]

My Conclusion

While it may seem — judging from popular opinion — that the verdict is in on back belts, the truth of the matter is, it’s not. We don’t really know if back belts help or not. (Maybe if those guys in Amsterdam would get off the pot…)

TeaTime

Anyway, what we do know is this:

  1. There is little evidence to suggest that they prevent back injuries, and
  2. There is the possibility that wearing them can lead to weak core muscles.

So, should you wear one or not? I guess it comes down to personal choice.

Until there is a truly definitive study, all we can do is speculate.

If you feel that wearing a belt helps support your back when lifting heavy objects, there seems to be no harm in doing so. However, you should probably only wear it when absolutely necessary.

My personal opinion (which is worthless, by the way) is that if you have a healthy back, you shouldn’t really need one. World-class athletes are able to lift safely without them.

Addendum:

By the way, if you’ve been wearing a lifting belt at the gym or at work, you shouldn’t just quit cold turkey. Instead, gradually wean yourself off of the belt as you condition your core muscles to take over that task.

The best way to do that would be to start out performing your preliminary (lighter) lifts without the belt while still using it for the heavy stuff. Then over the next few weeks progressively increase the weight you lift au natural, until you no longer need the belt for support.

Take care,
Dean

References:

1. Martimo KP, Verbeek J, Karppinen J, Furlan AD, Takala EP, Kuijer PP, Jauhiainen M, Viikari-Juntura E. Effect of training and lifting equipment for preventing back pain in lifting and handling: systematic review. BMJ. 2008 Feb 23;336(7641):429-31.

2. Ammendolia C, Kerr MS, Bombardier C. Back belt use for prevention of occupational low back pain: a systematic review. J Manipulative Physiol Ther. 2005 Feb;28(2):128-34.

3. Jellema P, van Tulder MW, van Poppel MN, Nachemson AL, Bouter LM. Lumbar supports for prevention and treatment of low back pain: a systematic review within the framework of the Cochrane Back Review Group. Spine. 2001 Feb 15;26(4):377-86.

4. Hodgson EA. Occupational back belt use: a literature review. AAOHN J. 1996 Sep;44(9):438-43.

5. Minor SD. Use of back belts in occupational settings. Phys Ther. 1996 Apr;76(4):403-8.

6. Wassell JT, Gardner LI, Landsittel DP, Johnston JJ, Johnston JM. A prospective study of back belts for prevention of back pain and injury. JAMA. 2000 Dec 6;284(21):2727-32.

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Writer's Block 23 Nov 2008 07:29 pm

Writer’s Block Nov 23

Nov. 23, 2008

Twisting and the Herniated Disc

This is Part 4 in the series I’m tentatively calling: “What Causes Herniated Discs?”

golf-swing-250w

In the previous installment, we discussed the various stress factors that contribute to disc failure and then examined one of those risk factors. This time I’d like to take a look at another one of those factors, but before we do that here’s a little something to refresh your memory:

“In physics, stress is classified according to type such as tensile strength (stretching the object), torsional strength (twisting the object), shear strength (lateral tearing of the object), and compressive strength (load bearing ability).

Of course, the normal intervertebral disc is designed to withstand all of these stress factors, but the two that appear to have the most impact on herniation are twisting and compressive loading.”

In that last article, we specifically looked at the effect of compressive loading and the role it plays in producing herniated discs. This time we’re going to examine torsional stress — sometimes referred to as axial torque — or what we laymen would simply call twisting.

And, for the sake of simplicity, we’re going to confine ourselves to answering the following three questions:

  1. What does twisting do to the walls of the disc?
  2. Can axial torque result in a herniated disc?
  3. What activities present the greatest risk for disc failure?

Let’s start with number one…

What Does Twisting Do to the Walls of the Disc?

You will recall that the outer portion of the disc is called the annulus and is a series of concentric rings of fibrous connective tissue that surrounds the nucleus much like a ring of forts built one inside the other.

Also, you may remember that the basic hypothesis is that as the disc dries out (either because of age, inactivity or both) the tough fibrous rings of the annulus start to break down and cracks begin to form. This process of deterioration is often referred to as degenerative disc disease.

So the question that is of most interest to us is what happens to this crumbling fortress when a twisting force is applied? McGill gives us a clue based on his observations…

“While we have not performed a lot of research on the effect of twisting on the discs, it appears that repeated twisting causes the annulus to slowly delaminate. This is evidenced by the tracking of the nucleus into the annulus in all directions. While we do not yet know the relationship between number of cycles and loads, we do know that added torsion reduces the compressive strength of the joint (Aultman et al., 2004).” [1]

That seems reasonable. If you take a sheet of rotten plywood and start flexing it, it would not be unexpected for the various layers to begin to separate (or delaminate as McGill puts it). So what about our next question:

Can Axial Torque Produce a Herniated Disc?

I believe that technically a disc can be considered herniated the moment the nucleus begins its initial break through the walls of the annulus even though it may not be to the point of causing a bulge and may be years away from actually extruding into the spinal canal.

So perhaps a better question might be, could a sudden twisting force cause a disc on the verge of rupturing to finally fail?

McGill gives us an interesting example that he and his colleagues observed during one of their research efforts:

“Our most recent work on disc herniation uncovered the dependency of the location of the herniating bulge on the axis of motion (Aultman et al., 2005). For example, in 20 motion segments, we flexed them repeatedly about an axis that was 30 degrees rotated from the pure flexion axis (mostly flexion with some lateral bend). One specimen simply failed abruptly and was removed…” [1]

When flexing disc segments about an axis of rotation, that is, ones that were twisted, one of them failed (herniated) immediately. The rest just took a little longer.

Again, this result comes as no surprise. It’s what you would expect to happen if you started applying torque to a weak disc. Perhaps a good analogy would be wringing the water out of a dishrag. Twisting the rag (disc) causes the liquid (nucleus) to seek a way out.

What is important to note is that this has been observed under laboratory conditions. It is not just the result of speculation.

So, since we know for a fact that twisting is a potentially harmful movement…

What activities present the greatest risk for disc failure?

baseballpitch1

The type of activity, which would apply a twisting force to the spine similar to what McGill is describing, would include such things as a golf swing, bowling, swinging a tennis racket, pitching a baseball, certain high velocity thrust-type spinal manipulations or any other forceful rotational movement.

None of the above activities are inherently dangerous or harmful to a healthy spine, but their cumulative effect needs to be recognized as a possible contributing factor to disc degeneration.

Discs that are not in perfect condition are no doubt going to be delaminating and accumulating additional cracks and tears each time one of these movements is performed.

And this says nothing about the impact of these activities on discs that are already in a weakened state and may be on the verge of catastrophic failure. Just teeing off on the ninth hole or bowling that last set may be all it takes.

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That’s as far as we’re going to go today, next time we’ll take a look at what I call “the Catch-22″ of rehabilitation, because there seems to be at least one hidden pitfall that we need to be aware of.

Till then,
Dean

References:

1. McGill, S. Low Back Disorders, Evidence-Based Prevention and Rehabilitation, 2nd Edition. (p. 44-47) Human Kinetics (2007)

2. Tampier C, Drake JD, Callaghan JP, McGill SM. Progressive disc herniation: an investigation of the mechanism using radiologic, histochemical, and microscopic dissection techniques on a porcine model. Spine. 2007 Dec 1;32(25):2869-74.

3. Drake JD, Aultman CD, McGill SM, Callaghan JP. The influence of static axial torque in combined loading on intervertebral joint failure mechanics using a porcine model. Clin Biomech (Bristol, Avon). 2005 Dec;20(10):1038-45.

4. Aultman CD, Drake JD, Callaghan JP, McGill SM. The effect of static torsion on the compressive strength of the spine: an in vitro analysis using a porcine spine model. Spine. 2004 Aug 1;29(15):E304-9.

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Writer's Block 15 Nov 2008 07:47 pm

Writer’s Block Nov 15

Nov 15, 2008

Sciatica and the Saline Story

syringe2

Could saline solution be the magic cure for sciatica and other forms of radiculopathy?

I don’t know. Maybe it’s a dumb question.

But one thing is certain. It has been used in research studies to effectively treat sciatica with the same success rate as epidural steroid injections.

What’s The Deal?

If you’ve read my series on epidural injections, then you know that at one time I was skeptical of their use for the treatment of sciatica. There were several reasons for this not the least of which was a research study that appeared back in 2003 that seemed to cast steroids in a bad light.

Here’s what an article written about that study had to say:

“July 1, 2003 – Steroid epidural injections are no better than saline epidural injections for sciatica, based on the results of a randomized, double-blind trial published in the June issue of the Annals of Rheumatic Diseases.” [1]

At that point — because I wasn’t very interested in steroids to begin with — I decided there was no reason to waste any more time on them and moved on to other topics.

It wasn’t until years later that I would find myself revisiting the subject with fresh eyes and a bit more interest than before. This time I wanted to find out as much as I could about steroid injections and whether or not they could in fact play a role in helping people rebuild their backs.

So naturally, as I was gathering reference materials, I went back and dug up that old research article and took another look at it.

Here are some of the highlights:

“In this study, 85 patients with sciatica lasting 15 to 180 days thought to be caused by disk herniation received three epidural injections, at two-day intervals, of 2 mL prednisolone acetate (50 mg) or 2 mL isotonic saline.” [1]

(In other words, half of the patients got the steroid and half received saline solution.)

“Treatment success was defined as recovery or marked improvement on self-evaluation scales at day 20…” [1]

And the results were…

“At the end of the study (day 35), 49% of treatment patients and 48% of control patients were in the “success” group…” [1]

Isn’t that interesting? There was a fifty percent success rate in both groups.

What This Study Does Not Show Us:

Despite my earlier dismissal of steroid injections, a closer examination makes it clear that this study did not prove that epidural steroid injections were not effective.

All it really demonstrated was that something else (saline solution) was also effective at relieving the symptoms of sciatic nerve pain.

What This Study Does Show Us:

Rather than casting steroid injections in a bad light, what this study actually seems to be telling us is that both treatments produced the same success rate.

“The efficacy of isotonic saline administered epidurally for sciatica cannot be excluded…” [2]

“Epidural saline injection for pain control in sciatica may or may not be efficacious.” [2]

This raises some very interesting questions:

Why were saline injections successful?

Is there a role for saline injections in treating sciatica?

Could saline injections (given either prior to, or post) enhance the results from steroid injections?

Since we know that some people are not candidates for steroid injections, perhaps they would respond favorably to epidural saline injections?

This might be worth asking your doctor about.

As always,
Dean

References:

1. Steroid No Better Than Saline Epidural Injections for Sciatica – Medscape

2. Valat, JP, et al. Epidural corticosteroid injections for sciatica: a randomised, double blind, controlled clinical trial. Ann Rheum Dis. 2003 Jul;62(7):639-643.

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