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 Post subject: Re: Bob's back rehab
PostPosted: Mon Sep 12, 2011 6:01 am 
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Generally, you will have been given at least one course of "rest and take anti-inflammatories" via a GP before the GP refers you. This depends on the GP, though. I can remember going to the same GP for a third time, and getting told to do the same again, still not getting a referral. I asked to see a different GP and he referred me straight away after about 5 minutes of him checking me out. However, you can speed things up if you actually ask for a referral instead of just saying "my -insert joint- hurts" , assuming the GP doesn't take it personally (it can be taken as you trying to tell them how to do their job).

BTW if you're not a student and you're fully employed you'll probably still need to pay for physio sessions (and it's not even that much less than someone private). Unless, of course, you're insured but even then, you may have an excess to pay which is normally the equivalent of about 4 sessions and you'll be lucky (or, unlucky) to need that many.

On top of that, the last person I spoke to who got a Physio referral was on an 8 week waiting list. This chops and changes but it's very rarely instantly. It's quite likely you'll be out of pain before you even get to the first session. Too many people in pain, and not enough physio's, in a time where the government is not in a position to do much about it, too.

I always question the logic in going to a GP first. Why not just source a good, reputable private physio, and just fork out and pay? The only reason I can think of is when things like lower back pain are actually kidney problems or worse i.e. not joint/muscle related, so there's maybe a reason there but, if you're sure it is joint related then why waste your time.

The problem you have as a lifter is that it's not a physio's job to get you back to lifting. It is the physio's job to get you out of pain. A lot of physio's only take a symptom based approach or what I flippantly refer to as "rubbing it better" (massage, stretches, etc for pain relief, definitely crucial but doesn't address the cause). You first of all want someone who will take a movement based approach - that's half the battle. The other half is finding one who understands exercise - this is a bonus! You may very well have physio's like this in the NHS. I'm sure you do. However, it's very much "luck of the draw" and I just think you're much better off finding someone reputable and even better someone who specialises in "sports injuries" or something similar. An athletic background is perfect because, for starters, you won't have these one's who are "against" things like squats.

To be honest I still don't believe there's anything "special" about what's going on with your back. However, when it comes to things like this, i'm incredibly optimistic.

All i've seen from your frustration, to be honest, is that you shouldn't be diving straight back into squats or dead lifts. Either that, or there's something really obvious going on (which a good physio would be able to spot straight away) and the very general things you are doing at the moment doesn't address it properly. It's worth noting that what you have been doing is very general infact what you have been doing is just what I would call "good training". A lot of it, too, is quite isolated. There's a saying "isolate then integrate". For example, being able to "activate" your glutes whilst lying on your back in a bridge position doesn't automatically mean you can now squat with maximal glute involvement. It's a start, but things get more complicated when you get up on your feet, and even more so when put a heavy bar on your back or in your hands.

KPj

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 Post subject: Re: Bob's back rehab
PostPosted: Mon Sep 12, 2011 6:49 am 
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yeah the last physio from the NHS I saw's advice was to take some anti-inflammatories (not that she "prescribed" them, I don't want the semantics police on my tail again hehe) and lie on my back with my knees bent and feet up in the air. Not exactly a long-term solution.

If I was to get put on an 8-week waiting list, I'd probably just do some squats the week before my appointment so the hurt was back and the physio could investigate. Not very scientific...

The main reason I want to fork out for this private guy is for exactly the reason you mentioned Kenny: that he'll understand exercise. He's not anti squats etc, he loves all that stuff so he'll do whatever he can to get me back squatting. I've never really thought about it the way you said - how a physio's responsibility is to get you pain free, not necessarily to get you deadlifting again - but it definitely makes sense.

I'm hoping there's nothing "special" wrong with my back. When I say it would be good just to know that I shouldn't ever squat or deadlift again, that's definitely not what I want; I just want an answer so I know what to expect. Believe me, I will be a very happy man if he tells me I can squat/dead again. It's just frustrating because I've done all this glute strengthening, core stengthening, mobility stuff etc, and progressed on it all; then I wait until I'm pain free, try a squat and then BAM! Sore again. There just doesn't seem to be any logic to it.

I'll just keep plugging away with my back friendly workouts til the physio gives me the all clear. What I'm expecting is that I'll go see him, he'll do his assessments or whatever then prescribe corrective exercise/stretches, then I'll go back and see him in like 6 weeks and he'll assess me again and either give me the all clear or give me more corrective stuff to do. That seems fairly likely.


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 Post subject: Re: Bob's back rehab
PostPosted: Mon Sep 12, 2011 6:55 am 
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KPj wrote:
I always question the logic in going to a GP first. Why not just source a good, reputable private physio, and just fork out and pay?


Why not do both? Going to your GP getting a referral isn't going to cost anything, what do you have to lose? Let's just say a private physio fixes Bob's problem after a few sessions, you then cancel the referral appointment from your GP. Nothing lost. But if the private physio can't fix the problem, for whatever reason ie. he needs a scan, then the process is already underway and he doesn't have to wait too long for a referral. It's a no brainer in my eyes.

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 Post subject: Re: Bob's back rehab
PostPosted: Mon Sep 12, 2011 9:32 am 
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robertscott wrote:
I'm hoping there's nothing "special" wrong with my back. When I say it would be good just to know that I shouldn't ever squat or deadlift again, that's definitely not what I want; I just want an answer so I know what to expect. Believe me, I will be a very happy man if he tells me I can squat/dead again. It's just frustrating because I've done all this glute strengthening, core stengthening, mobility stuff etc, and progressed on it all; then I wait until I'm pain free, try a squat and then BAM! Sore again. There just doesn't seem to be any logic to it.


There could be plenty of logic in it. As an example, lets assume your "forward bending pattern" (toe touch) sucks. I know of a lot of renowned physical therapists who won't allow you to DL if this isn't right (i.e. gray cook, charlie wiengroff). So, you stop the offending exercise (DL's). Meanwhile you do all this core stuff, you get better at it, and the pain also diminishes/goes away. However, your forward bending pattern still sucks. So you go straight back to deadlifts and, "bam", it hurts again - despite all the improvements in the "core" work you've doing. There's logic in it because the underlying cause (faulty forward bending) is still there.

Basically, just because you can plank for longer and get a good contraction in your glutes whilst lying on your back, you're not necessarily going to be able to forward bend any better. A lot changes when you get up on your feet. It changes even more when you add load (although, it shouldn't, assuming you have adequate foundation of movement, and progress load properly). I've lost count of the amount of people I have put on their back and had them "squat" deep with a perfect spine position, only to see their form crumble when asked to do it standing up. For a lot of people, there needs to be something in between doing these things in isolation/on the floor and integration/on your feet. It's a big jump going straight to your feet.

I am actually a perfect example of this right now. I didn't DL until I could touch my toes. I couldn't post injury because the hamstring restricted me. When I could, I started with RDL's and DL's off blocks. Then went to the floor and gradually progressed in weight. I knew it didn't feel right but couldn't figure out why. Went to the physio and discovered I was rotating on the toe touch because the hamstring I tore is still a little restricted and also doesn't fire up. This means that DL's are a recipe for back pain for me. So, I can't DL until I clear the toe touch... I thought it was really complicated but it's actually really simple. I assumed my toe touch was fine because, well, I could touch my toes. I didn't consider how I actually move when touching my toes. A GOOD physio will nail this for you in 10-20 minutes...

Basically, I think you're probably missing an essential foundation of "movement". Movement is everything. You build strength/power/endurance/whatever ON TOP of movement. If the underlying movement ability isn't there, then eventually your strength will exceed your ability to safely support the stress you impose on your body. This is when pain presents itself. As Gray Cook says, "building fitness on top of dysfunction".

You need to identify and fix the dysfunction. The pain is merely an alarm bell letting you know that dysfunction is present. Other than that it's almost irrelevant. Quite often all the "symptom" tells us is that there's something wrong. Not "what" is wrong. I mean, lower back pain can occur in the presence of shoulder dysfunction. In that case the pain is almost misleading...

KPj

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 Post subject: Re: Bob's back rehab
PostPosted: Mon Sep 12, 2011 10:40 am 
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It's funny you say that Kenny, because I'd actually come to a similar conclusion: it's all because my movement sucks.

For example, I can't do the toe-touch (I'm assuming you mean the one from Athletic Body in Balance). Not even close. I've been too scared to try it because I'm scared of flexion, but I guess if Gray Cook recommends it it's probably a good idea. I was just waiting til I could bend pain free before trying it.

So what's the step between doing it on the floor and on doing it on your feet?


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 Post subject: Re: Bob's back rehab
PostPosted: Mon Sep 12, 2011 11:47 am 
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Proper Knob wrote:
Why not do both? Going to your GP getting a referral isn't going to cost anything, what do you have to lose? Let's just say a private physio fixes Bob's problem after a few sessions, you then cancel the referral appointment from your GP. Nothing lost. But if the private physio can't fix the problem, for whatever reason ie. he needs a scan, then the process is already underway and he doesn't have to wait too long for a referral. It's a no brainer in my eyes.


I think I would only go see the GP after I've been to see the physio, I would hate to think I was wasting a doctor's time.


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 Post subject: Re: Bob's back rehab
PostPosted: Mon Sep 12, 2011 12:38 pm 
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robertscott wrote:
I think I would only go see the GP after I've been to see the physio, I would hate to think I was wasting a doctor's time.


I would hardly call it wasting a doctor's time Bob. You ask for a referral, when the appointment comes through if you still need it you take it, if not cancel it.

But, each to their own.

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 Post subject: Re: Bob's back rehab
PostPosted: Mon Sep 12, 2011 1:59 pm 
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I appreciate the suggestion, but I think I'd be better off waiting to see if I need to doctor before I contact one. Should hopefully find out one way or the other soon


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 Post subject: Re: Bob's back rehab
PostPosted: Mon Sep 12, 2011 10:23 pm 
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I feel like I need to send kpj some money.


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 Post subject: Re: Bob's back rehab
PostPosted: Tue Sep 13, 2011 2:26 am 
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About a GP "taking it personally". There's no reason why he/she should if you approach it right. Say something like "I've had this pain for a long time. I've tried rest and I've taken ibuprophen. I've even tried to find some corrective exercises on my own, but each time the pain comes back." The GP should do some simple screening exams (straight-leg-raises, "FABER" (flexion, abduction, external rotation) maneuver), reflexes) and ask about bowel and bladder dysfunction and whether the pain radiates to the legs, whether you have numbness or weakness in the legs. If any of that raises a "red flag" obviously he/she will order other tests or refer you to a specialist. Otherwise, I'd be surprised if there's a GP who wouldn't say, "you're right--PT would be a great idea. Here's a referral to one I know and trust". Of course in your system he/she may not have a choice of physios to refer you to, but in the US we would.

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 Post subject: Re: Bob's back rehab
PostPosted: Tue Sep 13, 2011 7:55 am 
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robertscott wrote:
It's funny you say that Kenny, because I'd actually come to a similar conclusion: it's all because my movement sucks.

For example, I can't do the toe-touch (I'm assuming you mean the one from Athletic Body in Balance). Not even close. I've been too scared to try it because I'm scared of flexion, but I guess if Gray Cook recommends it it's probably a good idea. I was just waiting til I could bend pain free before trying it.

So what's the step between doing it on the floor and on doing it on your feet?


Don't be scared of flexion. Flexion is necessary. Also, there's a difference between how you should be able to MOVE and you how should TRAIN. Just because it's preferential to avoid training lumbar flexion in the gym, does not mean we should avoid having the ability to flex the lumbar spine.

You can't achieve real stability without first having full mobility. You need movement first. This works from the perspective of viewing your body as an integrated unit (specifically - the joint by joint approach). For example, if your hips and upper spine are restricted, then you lose stability at the lumbar spine via compensation. In that case, plank and bridge all you like - you're always going to rely on lumbar spine too much if you don't free up the movement you SHOULD have in T-spine and hips. In fact you most likely already have a stable lumbar spine but you won't realise this until you free up movement else where and give it a chance to realise it's potential (for stability and the transfer of force). YOu may not even be doing a movement that requires full ROM at T-spine and hips but, your body doesn't know any better (because it doesn't know what full T-spine and hip mobility feels like), so it will rely on lumbar spine anyway.

It also works from an isolated perspective, too. If your lumbar spine can't flex, then you're stuck in extension. How is your body able to get into the middle, or midline (remember, to go from extension to neutral, you need to flex) - the position needed to utilise the surrounding local and global stablisers. Your abs, glutes, even multifidus, transverse abdominis, for example, are at a mechanical disadvantage if your lower spine is stuck in extension and can't flex and get into the middle. Now you need to rely too much on the lumbar extensors, hip flexors, QL,etc, to get stable. Charlie Weingroff refers to this as the "core pendulum theory". Opening yourself up to true stability won't just keep you out of pain, it'll make you lift better/more!

The next step from floor to feet is too specific to try and guess over the net. I'm hoping your physio is going to nail this for you. The example i used previously was squatting. If I get someone - particularly female - who can't squat well or deep, I lay them on their back, get their spine into neutral (normally by getting them to put one arm under the lower back), and lift the knees. Normally (especially women), they will be in a perfect deep squat position only, they're lying on their back (I clear the ankles via other means). Now, sometimes, they genuinely need to do all the stuff you've been doing and, "bam", couple of weeks later, we have a good squat. Other times, I just need to coach them how to squat properly and they achieve it within 20 minutes. I guess my point is I need to see you move to help with that.

Worth saying that failing the toe touch doesn't automatically mean you need more lumbar flexion. A lot of the time it's hips that lock up on this test. The toe touch, I bet, will be one of the first things you are asked to do.

KPj

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 Post subject: Re: Bob's back rehab
PostPosted: Tue Sep 13, 2011 8:01 am 
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Jungledoc wrote:
About a GP "taking it personally". There's no reason why he/she should if you approach it right. Say something like "I've had this pain for a long time. I've tried rest and I've taken ibuprophen. I've even tried to find some corrective exercises on my own, but each time the pain comes back." The GP should do some simple screening exams (straight-leg-raises, "FABER" (flexion, abduction, external rotation) maneuver), reflexes) and ask about bowel and bladder dysfunction and whether the pain radiates to the legs, whether you have numbness or weakness in the legs. If any of that raises a "red flag" obviously he/she will order other tests or refer you to a specialist. Otherwise, I'd be surprised if there's a GP who wouldn't say, "you're right--PT would be a great idea. Here's a referral to one I know and trust". Of course in your system he/she may not have a choice of physios to refer you to, but in the US we would.


Yeh, worth noting i've only ever had one bad experience with a Doc that seemed to hate lifting, so there's a little bias there. From what I know of the NHS, though, it's just completely over run. There's a waiting list for everything, and the people working there have far too many people to see.

I do know that private physios can take referrals from GP's. I don't know how it works but, I know my physio does some work like this. I've also started training a GP who already knew my physio because he refers patients to him. Normally, via the NHS, you will see a physio based in one of our hospitals but it seems the GP can refer you elsewhere. My physio works in his own facility. I'm not really sure how it works exactly but they do seem to be able to pick and choose as they see fit.

KPj

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 Post subject: Re: Bob's back rehab
PostPosted: Tue Sep 13, 2011 11:37 am 
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thanks as always for such detailed info Kenny. It's not so much that I was scared of flexion, just that I thought it was best avoided until my back was better.

You've convinced me: toe touch progression it is from now on! I'm going to start tonight. I'll do 5 sets over the course of the evening every evening, supersetting it with thoracic extensions.

Does that sound about right? Is there anything else I should add?


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 Post subject: Re: Bob's back rehab
PostPosted: Tue Sep 13, 2011 11:39 am 
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oh yeah and unfortunately I've had to postpone the trip to the physio because of financial issues. The issue being I have no finances.


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 Post subject: Re: Bob's back rehab
PostPosted: Tue Sep 13, 2011 1:12 pm 
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robertscott wrote:
oh yeah and unfortunately I've had to postpone the trip to the physio because of financial issues. The issue being I have no finances.


:lol:
did you just decide to go blow it on dancing and drinking?


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