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
Lower back pain will affect most adults at least once in their life time. Some individuals are lucky and only experience an acute bout of back pain. Others are less fortunate and progress into a state of chronic lower back pain. The good news is that a number of chronic lower back pain patients can benefit from a carefully structured exercise programme and lifestyle modification.
Exercise can help in reducing lower back pain and associated functional disability. However, when it comes to determining what the “right” kind of exercise is, it may become difficult to determine fact from fiction with so many opinions available online. There is an overwhelming amount of information on exercise rehabilitation for lower back pain and unfortunately a lot of misinformation. Sifting the truth from post-truth can be tricky.
That is why it is important to look deeper than just blogs and social media shares. That is where the Cochrane group comes in. They are the scientists who scrutinise scientists and keep the public up to date on relevant topics.
Cochrane reviews on exercise and low back pain
What is a Cochrane review? Cochrane reviews are systematic reviews of primary research in human health care and health policy. Cochrane reviews are internationally recognized as the highest standard in evidence-based health care. They investigate the effects of interventions for prevention, treatment and rehabilitation. They also assess the accuracy of diagnostic tests for some conditions in a specific patient group and setting. Cochrane reviews are published online in the Cochrane Library (LINK).
Who are the Cochrane Back and Neck group?
Cochrane Back and Neck (CBN) [formerly the Cochrane Back Review Group (CBRG)] is one of over 50 international Cochrane review Groups. The CBN coordinates the publication of literature reviews of diagnosis, primary and secondary prevention and treatment of neck and back pain and other spinal disorders, excluding inflammatory diseases and fractures (LINK)
1) Motor control exercise for acute non-specific low back pain. (LINK) Summary: Motor control exercise (isolating specific muscles such as Transversus Abdominus) showed no benefit over spinal manipulative therapy, other forms of exercise or medical treatment for reducing pain or disability among patients with acute and subacute LBP.
Review question: To evaluate the effectiveness of motor control exercise (MCE) (isolating specific muscles such as Transversus Abdominus) for patients with acutenon-specific low back pain (LBP).
Background: LBP is a common disorder that is often associated with pain and disability. One common intervention for patients with LBP is exercise therapy, and MCE is widely used for these patients. However, its effectiveness for patients with acute LBP remains unclear.
Search date: Evidence is current to April 2015.
Study characteristics: The Cochrane Library included in the review three trials evaluating acute or subacute pain in patients with LBP (n = 197 participants). Most participants were middle-aged and were recruited from primary or tertiary care centres. Duration of treatment programmes ranged from four weeks to six weeks.
Key results: MCE showed no benefit over spinal manipulative therapy, other forms of exercise or medical treatment for reducing pain or disability among patients with acute and subacute LBP. Whether MCE can prevent recurrences of LBP remains unclear.
Quality of the evidence: Results of this review include evidence of very low to moderate quality. The Cochrane back and neck group downgraded all comparisons for imprecision due to small study sample sizes.
2) Motor control exercise for chronic non-specific low-back pain. (LINK)
Summary: Little or no difference is observed between Motor control exercise (isolating specific muscles such as Transversus Abdominus) and other forms of exercise. (Given the minimal evidence that MCE is superior to other forms of exercise, the choice of exercise for chronic LBP should probably depend on patient or therapist preferences, therapist training, costs and safety.)
Review question: To evaluate the effectiveness of motor control exercise (MCE)(isolating specific muscles such as Transversus Abdominus) in patients with chronic non-specific low back pain (LBP).
Background: Motor control exercise is a popular form of exercise that aims to restore co-ordinated and efficient use of the muscles that control and support the spine. Patients are initially guided by a therapist to practise normal use of the muscles during simple tasks. As the patient’s skill increases the exercises are progressed to more complex and functional tasks involving the muscles of the trunk and limbs.
Search date: The evidence is current to April 2015.
Study characteristics: In total, 2431 participants were enrolled in 29 trials. The study sample sizes ranged from 20 to 323 participants, and most of them were middle-aged people recruited from primary or tertiary care. The duration of the treatment programmes ranged from 20 days to 12 weeks, and the number of treatment sessions ranged from one to five sessions per week. Sixteen trials compared MCE with other types of exercises, seven trials compared MCE with minimal intervention, five trials compared MCE with manual therapy, three trials compared MCE with a combination of exercise and electrophysical agents, and one trial compared MCE with telerehabilitation based on home exercises.
Key results and quality of evidence: MCE probably provides better improvements in pain, function and global impression of recovery than minimal intervention at all follow-up periods. MCE may provide slightly better improvements than exercise and electrophysical agents for pain, disability, global impression of recovery and the physical component of quality of life in the short and intermediate term. There is probably little or no difference between MCE and manual therapy for all outcomes and follow-up periods. Little or no difference is observed between MCE and other forms of exercise. Given the minimal evidence that MCE is superior to other forms of exercise, the choice of exercise for chronic LBP should probably depend on patient or therapist preferences, therapist training, costs and safety.
Summary: The overall quality of the evidence in this review ranged from low to moderate. There is some evidence for the effectiveness of Pilates for low back pain, but there is no conclusive evidence that it is superior to other forms of exercise.
Review question: To determine the effects of the Pilates method for patients with non-specific acute, subacute or chronic low back pain.
Background: Low back pain is an important health problem around the world. One of the most common treatments is exercise and in recent years Pilates has been a common option for treating low back pain.
Search date: The Cochrane back and neck group conducted searches up to March 2014. They updated the search in June 2015 but these results have not yet been incorporated.
Study characteristics: This review included 10 studies and 510 patients. All studies included a similar population of people with non-specific low back pain. The studies only included participants with chronic low back pain. The duration of the treatment programmes in the included trials ranged from 10 days to 90 days. The duration of follow-up varied from four weeks to six months. None of the included studies measured follow-up beyond six months. The sample sizes ranged from 17 to 87 participants.
Key results: The included studies demonstrated that Pilates is probably more effective than minimal intervention in the short and intermediate term for pain and disability outcomes, and more effective than minimal intervention for improvement in function and global impression of recovery in the short term. Pilates is probably not more effective than other exercises for pain and disability in the short and intermediate term. For function, other exercises were more effective than Pilates at intermediate-term follow-up, but not at short-term follow-up. Thus, while there is some evidence for the effectiveness of Pilates for low back pain, there is no conclusive evidence that it is superior to other forms of exercise. Minor or no adverse events were reported for the interventions in this review.
Quality of evidence: The overall quality of the evidence in this review ranged from low to moderate.
4) Exercises for adolescent idiopathic scoliosis. (LINK)
Summary: No evidence for or against scoliosis specific exercises. The two included studies yielded very low quality evidence that SSEs added to other treatments are more effective than electrical stimulation, traction and posture training for avoiding curve progression, and that SSEs as a standalone treatment yield almost the same results as general physiotherapy.
Adolescent idiopathic scoliosis (AIS) is a rare (2% to 3% of the general population) spinal deformity affecting young people aged 10 through the end of the growth period. The deformity may continue into adulthood. AIS is characterised by one or more three-dimensional spinal curves. Disability, cosmetic deformity, pain, activity limitation, quality of life issues, breathing problems and the possibility of the scoliosis remaining with the person into and throughout adulthood are commonly associated with this condition. The cause of AIS is unknown.
Treatment for AIS varies according to the degree of severity of the curves. Just the same, exercise is almost always a part of the treatment plan. In milder cases, exercise may be the main treatment, and in more severe cases it may serve as an adjunct. In the UK and the US, physical therapy for scoliosis consists mainly of general strengthening and stretching exercises, along with exercise protocols with which the treating therapist is familiar. There is a corresponding feeling among practitioners in these geographical locations that physical therapy for scoliosis is not effective.
Scoliosis specific exercises (SSEs) are individualised exercises aimed at reducing the deformity. SSEs are taught in clinics that specialize in scoliosis. The exercises work by changing the soft tissue that affects the spine. SSEs are also thought to work by altering control of spinal movement. There are no known side effects or risks to using SSEs.
The purpose of this review was to evaluate the effectiveness of SSEs in reducing curve progression and postponing or avoiding invasive treatment such as surgery in adolescents with AIS. Two studies involving 154 patients total were included. The review found no evidences for or against SSE. The two included studies yielded very low quality evidence that SSEs added to other treatments are more effective than electrical stimulation, traction and posture training for avoiding curve progression, and that SSEs as a standalone treatment yield almost the same results as general physiotherapy.
Possible limitations of this review included the small number of studies that met the inclusion criteria and a high risk of bias, particularly selection bias. More randomised controlled trials are needed in this area, along with a deeper understanding of the types of SSEs useful for the adolescent with AIS.
5) Exercises for prevention of recurrences of low-back pain. (LINK)
Summary: Moderate quality evidence that post-treatment exercises can reduce both the rate and the number of recurrences of back pain. However, the results of exercise treatment studies were conflicting. Limitations of this review include the difference in exercises across studies, thus making it difficult to specify the content of such a programme to prevent back pain recurrences.
Back pain is a common disorder that has a tendency to recur. The Cochrane back and neck group conducted this review to see if exercises, either as part of treatment or as a post-treatment programme could reduce back pain recurrences. The Cochrane back and neck group searched for studies that included persons with back pain experience, interventions consisting of only exercises and that measured recurrences of back pain.
There were nine studies with 1520 participants. There was moderate quality evidence that post-treatment exercises can reduce both the rate and the number of recurrences of back pain. However, the results of exercise treatment studies were conflicting.
Adverse (side) effects of exercising were not mentioned in any of the studies. Limitations of this review include the difference in exercises across studies, thus making it difficult to specify the content of such a programme to prevent back pain recurrences.
6) Exercise therapy for treatment of non-specific low back pain. (LINK) Summary: Exercise therapy appears to be slightly effective at decreasing pain and improving function in adults with chronic low-back pain. For patients with acute low-back pain, exercise therapy is as effective as either no treatment or other conservative treatments.
Exercise therapy appears to be slightly effective at decreasing pain and improving function in adults with chronic low-back pain, particularly in populations visiting a healthcare provider. In adults with subacute low-back pain there is some evidence that a graded activity program improves absenteeism outcomes, though evidence for other types of exercise is unclear. For patients with acute low-back pain, exercise therapy is as effective as either no treatment or other conservative treatments.
1) Motor control exercise for acute low back pain:
Are motor control exercises better than spinal manipulative therapy for acute low back pain? No
Are motor control exercises better than other forms of exercise for acute low back pain? No
Are motor control exercises better than other forms of medical treatment for reducing pain or disability? No
2) Motor control exercise for chronic low back pain:
Are motor control exercises better than other forms of exercise for chronic low back pain? No
Does the therapist’s training / qualification / background have an effect on exercises for chronic low back pain? Yes
3) Pilates for low back pain:
Is Pilates effective for treating low back pain? Yes
Is Pilates superior to other forms of exercise in treating low back pain? No
4) Exercises for adolescent idiopathic scoliosis:
Are scoliosis specific exercises effective as a stand alone intervention? Limited evidence
Are scoliosis specific exercises effective as an additive to other interventions? Limited evidence
5) Exercises for prevention of recurrences of low back pain:
Are exercises able to prevent recurrences of low back pain? Limited evidence
6) Exercise therapy for treatment of low back pain:
Is exercise therapy effective at decreasing pain and improving function in adults with chronic low back pain? Yes
Is exercise therapy more effective than no treatment or other conservative treatments for acute low back pain? No
Take home message:
Can exercise help with low back pain?
It depends on the nature and duration of the back pain as well as the type of exercise.
Chronic non-specific low back pain can benefit from exercise rehabilitation.
Acute low back pain and specific (neurogeneic, discogenic, spondylilosthesis, etc.) conditions may respond better to other modalities initially.
What type of exercise will help with chronic low back pain?
There is no consensus on one definitive exercise intervention. Therefore it is wise to steer clear of dogmatic approaches and practitioners that give guarantees on their particular modality. The data above indicates that Pilates and core stability (motor control exercise), which have been heralded as a cure for back pain, are not superior to general exercise. Movement is good, but using the right kind of exercise at the right time is important. Patients need to find a practitioner that can assess their needs and give them an exercise intervention that is tailor made to their needs, not to dogmatic beliefs.
Is Biokinetics for me?
Ask your Orthopaedic Surgeon (back specialist), GP or Physiotherapist if they feel that you may benefit from seeing an exercise specialist like a Biokineticist. Otherwise contact your local Biokineticist directly to discuss your case history. If you are not a suitable candidate the Biokineticist will refer you back to your Specialist / Physiotherapist for more information / treatment.
Published Cochrane review articles on exercise for low back pain:
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.