Telehealth and telerehabilitation for the COVID-19 lock-down.
South Africa went into a COVID-19 lock-down on 26 March 2020, following a directive from President Cyril Ramaphosa. The lock-down period prevents non-essential medical professionals from working with patients in a face-to-face context. However, the Health Professions Council of South Africa (HPCSA) has modified the online consultation guidelines to allow practitioners to consult with new, and existing, patients using telehealth. Telehealth in this context includes “telerehabilitation” by means of end-to-end encrypted video messaging. These digital consultations will only be allowed during the COVID-19 lock-down, and allegedly will revert to the pre-lock-down guidelines as soon as the Presidential directive ends.
If you are feeling confined during the lock-down and want to work on unresolved injuries, then a telehealth consultation followed by some telerehabilitation could be a solution for you. This lock-down period may actually provide you with an ideal opportunity to work on any unresolved injury issues or give you a chance to improve your physical health. Doing some exercise rehabilitation may also provide you with a means of killing boredom and maintaining your sanity.
If you are injured, or want to work on your physical health, you can contact a biokineticst or physiotherapist in your area. Otherwise reach out to a physiotherapist or biokineticist that you have a good working relationship with to see if they are offering online consultations. If you are not a suitable candidate for telehealth, or telerehabilitation, you will be asked to wait until after the lock-down has ended, or referred on for a face-to-face consultation if your condition is serious and warrants immediate care.
The title image of this post is an artists’ rendition of Philippe Petit’s 1974 high-wire walk between the previous Twin Towers of New York’s World Trade Center. Petit wrote a book: “To Reach the Clouds”, which was later release in paperback under the title “Man on Wire”.
The relevance of this image to this post cannot be understated. Petit’s unrivaled feat of balance and stability is an undisputed display that stability comes from control of movement, not the prevention of it. Philippe Petit would never have achieved his walk between the towers if he had been rigid. Faced with upwinds, crosswinds and a moving wire he had to use a dynamic approach to balance. He was so well poised that he was even able to lie down on the wire at the half way point. To watch his amazing achievement, and the beautiful dance on the wire you can watch it on the 2008 film Man on Wire.
Paul Hodges on balancing mobility and stability:
Paul Hodges is a Professor at the University of Queensland with over 520 research items listed on Researchgate. He is well respected with over twenty-three thousand citations. His main area of focus is listed as “Neuromotor control of movement and stability, and changes in this system with pain”.
Current themes that Professor Hodges is working on:
Physiology and pathophysiology of movement control mechanisms.
Integration of neuroscience and biomechanics to investigate the nervous system control of joint stability and movement.
Effect of conflicting task demands control on spinal control.
Biomechanical effect of contraction of the intrinsic spinal muscles on stability of the spine.
The effect of pain on motor control and possible mechanisms.
According to Paul Hodges there are three major misconceptions with regards to “core stability”:
1) Misconception: It is all about stiffness
2) Misconception: It is all about one muscle (or a select handful of muscles)
3) Misconception: There is a one size fits all approach to fixing back pain
Reality 1: It is about dynamic control.
Different tasks place different demands on the body. Some movements require more stiffness/bracing while others require more fluidity. The dynamic control for weight lifting for example is different to the dynamic control of running. Weight lifting may require more stiffness, while the same level of stiffness applied to running would be detrimental to performance, and may lead to injury.
Dynamic control is therefore the control of movement relative to task, rather than the prevention of it. Too many pseudo-core routines are designed around rigidity, stiffness and the prevention of movement. A plank is a prime example. Thousands, if not millions, of planks are performed annually with the belief that they are core-centric. However, a plank is not a core stability exercise, it is a pain tolerance exercise. Planks are terminated after a set time limit or due to pain in the shoulders/lower back. They are not terminated due to core fatigue or loss of stability.
Reality 2: The body is a complex system of neuro-muscular-skeletal interactions.
There is more to the body than just one muscle or a select group of muscles. A number of paradigms promote the training / re-training of the Transversus Abdominus, which has been shown to be an important muscle for stability of the torso. It is hypothesised that the Transversus Abdominus achieves this by increasing its thickness and consequently the intra-abdominal pressure. However, it is one muscle. It is a local stabiliser, that is believed to fatigue quickly, and does not produce movement. It is therefore part of the puzzle, not the only piece. Countless patient hours are devoted to this muscle (along with Multifidus) using motor control exercises (precise movements aimed at “isolating” the muscles) at the expense of general exercise (cardio / weights / flexibility).
Reality 3: There is no one size fits all.
No two patients are the same. Some back cases may have similar signs and symptoms but the human being experiencing the back pain is unique and needs to have a unique case management. Too often the approach is a one size fits all. In a best case scenario a patient should be given a bespoke exercise programme tailor made to their individual injury needs, goals and lifestyle.
The problem with the term “core”:
We have a problem in the rehabilitation/fitness industry: an obsession with the term “core”. The word core is reductionist in itself. It should be core + stability = core stability. In actual fact it is the stability component that should get the emphasis, not just the core. Stability of the body is not derived from one particular system or isolated area of the anatomy. Nothing in the human body works in isolation. It is a “symphony” of Newtons 3rd law: action and reaction.
Medical professionals, trainers and the media have created a nervous condition involving a misinformed belief system that there is a catastrophic lack of spinal stability, and the only remedy is to “fix” the “core”. This paranoia can be conceptualised as a Corexia-nervousa or Core-dysmorphic-disorder . Even though most patients have limited concept of what the core is anatomically, they know that they have to have one. It is like a magical unicorn, or pot of gold at the end of a rainbow.
We have created a generation of patients that believe that the centre of their back pain problem is due only to the lack of “core”. Their misconstrued philosophy is that the more core they do the better they will be. Unfortunately, there is never enough core in their minds. And if you do not give them core, the patient believes that their back will be left vulnerable. The tragedy of this scenario is that the seed of this misinformation is often planted by a medical professional. The spine is hugely resilient. It is not a dry twig waiting to snap at a moment’s notice.
Evidence against the “Corexia” / lack-of-core paradigm exists, but patients and practitioners choose to ignore it. If you listen to Dr Fiona Wilson on the following soundcloud interview (Treating low back pain in sport: Dr Fiona Wilson. ) you will hear how some patient population groups have a direct correlation between amount of time spent on core, and back pain. What on earth does that mean?: it means that the more core training that this particular patient group performed the more likely they were to experience back pain. This can be attributed to both volume but also the type of exercise included in a core routine. Clearly we are getting it wrong! Lack of “core” is not the problem.
Advancing with the times:
If you are shoved into a generic Pilates class or force-fed the same tired dogma of “core” it is time for a change. It is important to read wider than just the echo chamber of core and Pilates posts in your local magazine or Facebook feed. If you need bespoke exercise advice, seek out a Biokineticist / Physiotherapist with special interest in low back rehabilitation, but do not settle for mediocrity. Science has evolved and the Biokineticist / Physiotherapist that claims to be current and up to date with best practice needs to give you way more than just core. Like Phillipe Petit on his wire, you need a dynamic approach to your movement.
References: Paul Hodges BJSM interview with Karim Khan: https://www.youtube.com/watch?v=hplw6Lg95SY Main image: http://www.perezosos.mx Image: PsyPost
The lower back (Medical term: low back) is an integral part of the entire human movement chain. It functions as part of a complex network of the skeletal, muscular and nervous systems. When the low back is injured it can affect one or all of these systems. As a result of its complex and undistinguished aetiology, the treatment for low back pain remains controversial.
Treatment options for low back pain include the following:
Nonsteroidal anti-inflammatory drugs.
Epidural steroid injections.
Transcutaneous electrical nerve stimulation.
Eighty to 90% of acute low back pain episodes dissipate within 8 – 12 weeks regardless of any intervention, but 5 – 10% regress into chronic low back pain.
Therapeutic exercises for chronic low back pain have been shown in numerous randomised controlled trials to be beneficial in reducing pain by up to 60% and improving functional ability by up to 47%. Furthermore, a Cochrane review on low back pain found evidence to support exercise therapy as an effective intervention in the treatment of chronic low back pain.
When prescribing exercises for an individual with low back pain the following goals need to be considered:
Improve performance in endurance activities.
Improve muscular strength around the spine.
Eliminate any impairments in spinal flexibility.
Reduce the intensity of the pain being experienced by the individual.
Reduce back pain-related disability.
Dr Mike Evans on Low Back Pain:
Dr Mike Evans posts user friendly videos on complex medical issues. He makes science and medicine simple. You can check out his videos on YouTube (LINK) or on his website (LINK). His whiteboard health videos are well worth the time.
Below is a summary of his whiteboard video on low back pain. The video link follows at the end of the post.
Summary of the video:
Low back pain is one of the top 2 reasons why people see their GP.
Low back pain accounts for 40% of all missed worked days in the USA.
Low back pain often resolves on its own without intervention. We can take care of ourselves.
Severity of the pain does not reflect the seriousness of the underlying problem.
30% recurrence in 6 months. 40% recurrence in 12 months.
We should view back pain as a chronic vulnerability, rather than discrete events.
It is important to have a “back resilience plan” and a support team to help.
Back pain pattern 1: Back dominant.
Pain is back dominant. Mostly in the low back.
Pain can radiate down to the glutes, hips, and legs, but is predominantly in the back.
There is relief with movement.
There are particular movements help alleviate the discomfort, and movements that aggravate it.
Often back “spasms”.
Some dominant pain is “good pain”. It is not associated with damage to the spinal cord or nerves. Often does not require surgery.
Back pain pattern 2: Leg dominant.
Often related to a disc problem (disc putting pressure on the nerves).
Pain travels down the legs (“sciatica” / Sciatic pain).
Pain down the leg – below the buttock to the foot.
The leg pain is dominant.
It is a constant pain that gets better with rest / lying down.
Sciatica often gets better on its own, But may need: Special advice, medication, imaging.
Leg pain is “predictable”. Certain activities / movements cause pain, other take it away.
Pain anywhere in the leg.
Heaviness that causes the individual to stop moving. Known as Neurogenic Claudication. It is related to stenosis / narrowing of the spinal canal. When severe it is hard for the nerves to keep up with activity.
Red flags: (may need more investigation)
Sudden change in bladder and bowel control (numbness around groin / rectal area).
Infection / TB.
Risk for fracture (Fall, motor vehicle accident, osteoporosis).
Cancer (Previous history of cancer, constant pain lasting weeks, not able to alleviate).
Diseases (Ankylosing Spondylitis).
Yellow flags: (attitude and outlook are important)
Belief that back pain is harmful or a disability.
Fear and avoidance of activity / movement.
Low mood isolation.
Belief that passive rather than active treatments will help.
Should I get an MRI / Xray?
A study by Prof Richard Deyo (LINK) showed that only 1/2500 back Xrays show a clinically significant finding.
What is the harm in getting a screening Xray? Radiation, cost, time.
One study with 98 asymptomatic subjects showed that 2/3rds had disc problems.