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Low back pain

A SACRUM TOO FAR – Tiger withdraws from Ryder Cup. What advice would we offer one of the world’s greatest ever golfers? Guest Blog @NicolvanDyk

16 Aug, 14 | by Karim Khan

Guest blog by sports physiotherapist @NicolvanDyk (Qatar)

By age 24, Tiger Woods had won more Majors than Jack Nicklaus. Now, aged nearly 39, Nicklaus is ahead. Graphic @BBCsport via @docandrewmurray

By age 24, Tiger Woods had won more Majors than Jack Nicklaus. Now, with TW aged nearly 39, Nicklaus is ahead. Graphic @BBCsport via @docandrewmurray

“If there’s a fork in the road, take it.” Yogi Berra

Tiger Woods has officially withdrawn from the Ryder Cup – a move that makes a lot more sense than his starting the PGA last week. It seems like he is now following sound medical advice. A proper break aimed at full recovery. He is aiming to return in December for the World Challenge tournament, which seems reasonable. But what will happen beyond that. What does his future hold?

That was the question some colleagues asked me at the Aspetar Orthopaedic and Sports Medicine Hospital on Wednesday (prompted by a recent blog from Prof Karim Khan (@BJSM_BMJ). How would I advise perhaps the greatest golfer ever? Can we base it on evidence?

I am sure we can. Sports Medicine Physicians and Physiotherapists make such assessments every day, from elite level athletes to all the rest of us. Here’s a short proposal that may resonate with many Sports Medicine clinicians’ reasoning in this scenario. (And to Mr. Woods, I would hope to think your team is doing the same.)  (And of course I’m keen to learn from those more expert than I).

  1. Correct Diagnosis (correction, hypothesis)

Let’s open the box and look inside. No, unfortunately no rabbit. It is rare for a single diagnosis to capture the full spectrum of what has transpired for an injury to happen. And no doubt, without any knowledge of the specific medical condition or advice Tiger Woods has received to this point, what we need to do first (or at least redo again) is work through some hypotheses, to  make a proper clinical diagnosis.

Unfortunately another MRI scan would most likely not help us (see reference here). Imaging is useful, and there are a couple of things we want to exclude, but what we see must make sense in light of the whole clinical picture. As a suggestion, let’s call it a holistic assessment. We need to look at all the aspects influencing current pain experience, playing performance, and then do a full musculoskeletal examination looking at movement patterns and muscle recruitment, to understand the current condition. It needs to include history, both past and present, classification based cognitive functional therapy (CB-CFT), pain science education, nutrition and conditioning.

Our diagnosis will perhaps not be catchy, or sexy like “sacrum out” or “disc popped”, but it will be as accurate and inclusive as possible, (maybe something like “intervertebral joint dysfunction with movement restriction into flexion”) which will guide us in our treatment and rehabilitation. This sort of thinking allows different information to be taken into account, it creates the opportunity to evolve if needed (conditions change over time) and allow us to adapt whatever treatment we choose to utilize. This is necessary for achieving our goal. And yes, then do need to identify the goal, but hang on, we’ll get to that. We need to have something to test ourselves again, and some objective signs we can measure – other than eyeballing the sacrum.

  1. Correct Treatment and Rehabilitation

Unlike our colleagues in the 70s, 80s and 90s, we do not have to rely on expert opinion anymore. Not that expert opinion is not important, or valuable, but in the context of modern sports medicine, we have a growing body of evidence to support what we do, and why we do it.

And in this scenario, here is the key message – exercise works.

It is a proven therapy that has been found in most cases to trump the quick manipulation, magic tape or the odd bit of dry needling (or a hug). The scientific search here would lead you to mechanotherapy, or mechanotransduction, but let’s not be distracted by the details right now.

Research (see here a great editorial by Prof Peter O’Sullivan (@PeteOSullivanPT) on how we manage back pain) tells us to strengthen and rehabilitate the correct movement patterns (for the individual, no recipe’s needed, thanks) rather than spend hours rubbing lotion on your back, or cracking things into place. Firstly, perhaps most importantly, we need to ensure that you understand and comprehend the condition, the pain and what it means to you as a person. And then, perhaps as important, we need you to move, and move as well as you can. (Note to TW, the writer is a qualified manual therapist). Next, a gradual return-to-play programme where you build up the necessary strength, endurance and loading of the structures in your back so that when you get back, you really are “good to go.”

  1. Finding the TEAM that works towards injury free* peak performance
    (*injury free = minimal risk of injury with maximum benefit from performance parameters)

Sports Medicine requires a team approach. And a good team will help you to integrate the evidence into a quality clinical decision. Of course I am not attempting to take away the complexities of these decisions in any way. But we have certainly come a long way from “the doctor said I shouldn’t play.”

Instead, we need to develop better algorithms to help make these decisions. Dr. Paul Dijkstra (@drpauldijkstra) has captured these difficulties in his open access BJSM article “Managing the health of the elite athlete: a new integrated performance health management and coaching model” highlights the difference when practicing integrated care medicine, and this article develops a health and performance grading system (see Table 3). This kind of system assists not only the Sports Medicine team, but it creates better understanding for the athlete of what all the information means.

Because related to rehabilitation that is (and should be) the main focus now, is performance. And having gone through 4 swing changes with 3 coaches in his career, Mr. Woods is hardly the same player as when he started. So has it backfired? And having the advantage of retrospection, was it worth it? Could these changes have influenced or played a part in the multiple knee injuries (and surgery) and ultimately the back injury leading to surgery this year?

Of course, the other question with any child prodigy who turns professional (and has a long, successful career) is load management. Prof Roald Bahr (@roaldbahr) from Norway suggests in a recent editorial for BJSM that “We now have the evidence to show that extra caution is needed when managing the gifted athlete.” Did we also fail Tiger Woods in this regard? Seeking to make the near perfect player even more perfect, asking too much of his gifted body?
Perhaps, although I am weary of the hindsight trap. We have to assess where we are now, and if we change anything again, it must be an integrated decision that allows ultimate performance with minimizing injury risk. Which brings us to perhaps the most pertinent question:

  1. The Risk-Reward Ratio – Will life after golf still allow playing some golf?

In 2008, aged 32, Tiger Woods had won 14 majors. It seemed likely (in an incredible fantastic way) that he would surpass Jack Nicklaus’ record of 18 majors. In December, when Tiger Wood plans to return, he turns 39. Is there still time? Jack Nicklaus was 46 when he won number 18, and a few other greats (Phil Mickelson, Ernie Els, Gary Player, Ben Hogan) have won majors in their 40s. But will he win another 5, with the rise of the young guns and the trail of injuries behind him? Mr. Woods wants to win majors, of that I am sure. But what will it take to win another four? What would be left? So here we have to ask, is the REWARD worth the RISK?

To really answer that question, we need to know from the athlete what the perceived reward is, versus the perceived risk. REWARD would be to hold the record number of major wins, to be the unchallenged greatest golfer that ever lived (if we classify greatest by number of major wins, although many might view Tiger Woods as the greatest already). REWARD would be to continue competing, and continue being the guy that everyone wants to beat (not sure if that’s true, but Jack Nicklaus still thinks so). REWARD could simply be to keep doing the thing you love to do, at the highest level. Yes, the rewards will be great. If this is indeed how TW sees the REWARD as well. So what then of the RISK?
There is a continuous effort among sports medicine researchers to identify risk factors for athletes, (e.g. IOC Injury Prevention Conference 2014). So when Sports Medicine Clinicians explain risk to an athlete, we try (or at least should attempt) to present all the information, and make the decision with all the components weighted. In this case, we have to consider the RISK of re-injury, of developing persistent pain, and dare I say, the RISK of not being able to continue playing golf at all? Have we even considered presenting out athlete with these scenarios? And more importantly, how we present this information, in a non-threatening and easy digestible way, might be crucial to the outcome

It’s a complex decision. But this needs thought, and all the possibilities considered. And I am not suggesting the answer is simple. Playing golf with the kids on a Saturday afternoon 20 years from now versus surpassing Jack’s record? (Oversimplification, I confess). It needs a sports medical team that is honest and clear, without seeking yes/no scenarios. (I would suggest this podcast by Prof Peter O’Sullivan here. He deals with the temptation to overdiagnose and overtreat brilliantly) And it would likely not be an “either/or” , but a “yes, and” answer that will allow the best outcome for the athlete.

As a sports physiotherapist, I wish Tiger Woods all the best with his rehabilitation and return to play. And I hope that he (and every elite professional athlete) will have the opportunity to make these decisions with the support of a good team and the value of current research and best practice guidelines driving the process.

Nicol van Dyk is a sports physiotherapist with special training in manual therapy. He is writing this in his personal capacity as a physiotherapist.



@PeterBrukner discusses today’s major headline: Successful antibiotic treatment in a subset of people with chronic low back pain

8 May, 13 | by Karim Khan

PB picIt is not often that something I read in the medical research literature gives me goosebumps and an incredible urge to tell everyone I know about it (thank god for Twitter!). I had that feeling today when, after an article in this morning’s Guardian newspaper, I read two recent papers published by a Danish group of researchers led by Hanne Albert in the European Spine Journal (links below).

Infection and low back pain!?

The papers relate to the possibility of an infective cause in a sub-group of patients with chronic low back pain. This sub-group is those patients with Modic changes. Modic changes (MC) are bone oedema in the adjoining vertebra to one in which there is a disc herniation. MC are present in 46% of patents with chronic low back pain compared to 6% in the general population. MC can only be reliably detected using MR imaging. A number of previous studies have demonstrated the presence of bacteria especially Propionbacterium acnes (P. acnes) in disc nucleus tissue evacuated at surgery from patients with lumbar disc herniation.

The first paper Does nuclear tissue infected with bacteria following disc herniations lead to Modic changes in the adjacent vertebrae? reports on 61 patients who had nuclear disc material removed while undergoing surgery for chronic low back pain. Microbiological cultures were positive in 28 (46%) patients, of which 26/28 were anaerobic cultures, 2 (3%) aerobic and 4 (7%) mixed. In the discs with a nucleus with anaerobic bacteria present, 80% developed MC in the vertebrae adjacent to the previous disc herniation, compared to none in the aerobic group and 44% with negative cultures. They concluded that the occurrence of MCs in the vertebrae adjacent to a previously herniated disc may be due to oedema surrounding an infected disc.

How do intervetebral discs become infected?

Organisms such as P. acnes are commonly found in hair follicles in the skin and in the oral cavity. They frequently invade the circulatory system during tooth brushing where they do not present an immediate risk because the blood stream is an aerobic environment. When an intervertebral disc is herniated, nuclear material extrudes into the spinal canal. Within a short time, neocapillarisation begins in and around the extruded nucleus material, inflammation occurs and brings with it macrophages. So far so good – no debate about any of that.

The innovation of the authors is their proposal that avascular and thus anaerobic disc provides an ideal environment for these anaerobic bacteria to flourish. In this setting, anaerobic bacteria that are normally inconsequential (low virulent) may enter the disc and give rise to a slowly developing infection.

Local inflammation in the adjacent bone (MC Type 1) may be a secondary effect due to cytokine production or microbial metabolites (e.g. propionic acid) entering the vertebrae through normal disc nutrition. P. acnes is known from the skin to trigger an adjacent inflammatory response. P. acnes cannot multiply in the highly vascular aerobic bone and are therefore not present where the MC occur.

All good in theory but what about an RCT?

The second paper is entitled Antibiotic treatment in patients with chronic low back pain and vertebral bone edema (Modic type 1 changes): a double-blind randomized clinical controlled trial of efficacy.  this paper reports the efficacy of antibiotic treatment in this group of patients with MC lesions and chronic low back pain. This double blind RCT study examined 162 patients with chronic low back pain (> 6 months duration) occurring after a previous disc herniation AND who had MC changes in the vertebrae adjacent to the previous herniation. Subjects were randomised to either 100 days of antibiotic treatment (Bioclavid) of two different dosages or placebo. Outcomes were evaluated at baseline, end of treatment and at 1 year follow up.

Primary outcomes were the well accepted disease-specific disability Roland Morris Questionnaire as well as the report of lumbar pain. The antibiotic group made highly statistically significant improvements on all outcome measures; the improvement continued from 100 days follow up until 1 year follow up. For example, on the disease specific disability, the antibiotic group was 15 at baseline, 11 at 100 days and 5.7 at 1 year compared to placebo (15, 14, 14). The report of lumbar pain decreased much more in the antibiotic group who started at a score of 6.7 and improved to scores of  5.0 (100 days) and 3.7 (1 year). The placebo group mean report of lumbar pain stayed constant at 6.3 from baseline through 100 days and 1 year (lower is better, of course).

Biologically plausible time course

Patients also reported that pain relief and improvement in disability commenced gradually, for most patients 6-8 weeks after the start of the antibiotic tablets and for some at the end of the treatment period. Improvements reportedly continued long after the end of the treatment period, at least for another 6 months, and some patients reported continuing improvement at 1-year follow up. The improvement seen in the antibiotic group at 1 year follow up was approximately twice that observed at the end of the 100 day treatment period, suggesting that a biological healing process that starts only when and after the bacteria have been killed.

Half the treatment group took one Bioclavid (amoxycillin-clavulanate 500mg/125mg) tablet three times a day while the other half took two tablets. The authors state that the long duration of antibiotic treatment is commonly prescribed for post-operative discitis. There was a trend towards an improvement with double dose, but did not reach significance.

What should we make of these papers?

This treatment is certainly an exciting possibility for one of the most difficult management challenges in medicine.  At this stage all the authors are saying is that in a particular sub-group of patients with chronic (>6 months) low back pain, those with Modic changes on MRI scan after lumbar disc herniation may respond well to long term antibiotic treatment. We are reluctant to prescribe long term antibiotics for reasons of potential development of resistance but there seems to be a rationale for long term use in this situation. Further studies need to assess the efficacy of shorter terms of treatment. Because this is the BJSM blog, we can point out to readers that the group’s pilot study was not accepted by a number of famous journals but saw the light of day via BJSM’s ‘peer-review fair review’ process. That paper came out in 2008.

I would think on the basis of this research it is reasonable to prescribe the recommended antibiotic program to those who strictly meet the clinical and MR imaging criteria. Especially if the only alternative seems to be surgery which has limited efficacy in these patients and is obviously vast more expensive than a course (albeit prolonged) of antibiotic therapy. Remember if you have this infection surgery will not be treating the cause.

It took the Nobel prize winning research  on Heliobacter and its relationship to stomach ulcers of West Australians Barry Marshall and Robin Warren to alert the skeptical medical community of the potential of infective causes of common conditions. Many investigators are currently seeking infective causes for a wide variety of common and uncommon medical disorders. This research will encourage such investigation. Undoubtedly we will find more causal infective relationships. Further work needs to be done to answer a range of questions (which antibiotic, what dose, how  long etc), but these two papers are an exciting step forward in the management of a very difficult condition. If I were a sufferer of chronic low back pain I would be feeling a little more optimistic after the publication of this research.

Dr Peter Brukner (@PeterBrukner)MBBS, FACSP, Sports Physician, Melbourne, Australia, is an experienced team physician and writing in his capacity at BJSM Senior Associate Editor and regular blogger.


Cover of December 2008 BJSM issue that included this group’s pilot study. We congratulate the Albert group of researchers for their persistent pursuit of better outcomes for patients – well done! For their 2008 BJSM paper see this link


BJSM author grabs Australia’s #1 researcher title

22 Dec, 10 | by Karim Khan

Physiotherapists have increasingly provided many of the major advances in sports and exercise medicine in the past 20 years and Professor Paul Hodges has been pre-eminent among them. 

Now we regularly see sport and exercise medicine papers in the BMJ, Lancet, JAMA and even the New England Journal of Medicine. This reflects the wave of improved research and the significance of our field in addressing major health problems. 

One objective measure of this new maturity in the field is grant success at national health research funding agencies. This too has been increasing for sport and exercise health researchers and clinicians in the past decades. 

Now Prof Hodges has been hailed as Australia’s #1 researcher. Remember that nation produced 10 Nobel Prize winners including Howard Florey, MacFarlane Burnet and more recently Barry Marshall and Robin Warren. (See link for classic rejection letter for Dr Marshall!) 

So up against cancer, genomics, personalized medicine and the like, Professor Hodges, the new slim-line marathon man incarnation, had taken the ultimate prize.

Good for him but knowing the man, he will be most pleased about his drawing attention to the important work of physiotherapists and their colleagues in research around the world.  

The December 2008 BJSM issue featured Professor Hodges’ work including the cover image and a key editorial — Transverus abdominis: a different view of the elephant.  His work has not been without its challengers (the sign of any iconoclastic research) and related articles in BJSM include a perspective from Garry Allison.



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