The Desk Jockey
I wanted to take you through a common “type” of back pain which too often is mis treated - namely we take care of the symptoms and not the actual cause of what is going on. I refer to this type of patient as a desk jockey.
I feel our role as health care practitioners is to make the complex look simple- and this is crucial when dealing with any type of low back pain.
Health care workers first visit with a back pain patient is often the most crucial and the language used during assessment and treatment and treatment planning with the patient can often set out the path.
What Is a Desk Jockey?
A Desk Jockey- is simply someone who has a desk based job and/or works at a desk for greater than 6 hours.
The Classic presentation of A Desk Jockeys Low Back pain is normally a diffuse or general ache across the back that is often worse at the end of the day after sitting.
This type of back pain patient tends to be very sedentary during the day and often complain of being chained to a desk- or feel they are unable to move about at work. You will hear things like:
- I can’t get up and move
- I will be less productive at work
- I’ll look funny if I move at work
With The Above In Mind I’d Like To Take You Guys Through How we at the Movement team would deal with the above.
Our Prime goal at the movement team is to make sure, above anything else, that the client walks out of our session with total understanding in their terms, why they have what they have got and what they need to do to make it better - notice the focus is on them. I can sound like a rocket scientist with lots of knowledge and big words, but if this isn't translated into something they understand you have just wasted the session.
With this in mind we would tend to look at the following - and this list is in order of priority. This is obviously after we have cleared all major red flags and pathophysiological issues within the lumbar spine - and in 99% of cases this will be done without the need for imaging in the first session as this often leads to a bad outcome in patients with low back pain.
1- Thoracic range of movement.
Thoracic range is often the reason why excessive force is translated to the lumbar spine. Whilst working in the English Premier League (EPL), we found that players with less than 15 degrees of thoracic extension would take an extra 60% of load through their lumbar spine.
2- How much do they sit
This is an obvious one- however often the most neglected question asked within low back pain.
- If someone stood with a 500g bottle of water out in front of them all day and complained that their bicep was tight and their elbow was stiff- would anyone suggest that they needed a massage on their bicep and some manual therapy to their elbow to “cure” their problem?
Between the first 2 elements - if you improved Tx range and decreased sitting to a minimum your would probably remove 80% of lower back pain without even touching a patient.
3 - Hip flexor tightness
The hip flexors (namely posts, illiacus and the deep hip flexors) are often a prime cause of causing minor flexion in the lumbar spine.
In soldiers across 3 infantry battalions in the UK with low back pain from Tabbing (Tactical Advance to Battle) we would find that a simple stretching regime of doing 3 x 3 minutes of stretching on the hip flexors decreased reporting of low back pain by approx 75%.
4- How much do they move?
Here is another obvious one to ask- how much do you move when not at work. If you have someone who watches movies all weekend or does more work outside of work you will obviously have a greater problem on your hand. With this person you could do the latest low level laser therapy, manual technique and soft tissue manipulation. Until you change the lack of movement problem you will again see this patient again and again with no obvious solution in sight.
Whats The Point?
Our 2nd Principal at the Movement Team is the Whats the Point principal.
As I alluded to earlier - you can perform the best technique, treatment, and approach all you like - however if there is no goal/reason/understanding behind this you will often get a bad result.
Our take is that we want a rough 85% change within 2-3 sessions - this is often the magic number where patients who get that change will often keep it.
If you are not getting this change there are 2 reasons why not:
1- There is a patient issue - not changed habitual patterns, have not moved enough outside the appointment or they simply do not understand enough to make a change.
2 - There is a diagnosis issue - you as the practitioner has not quite nailed the reasons why they are getting pain.
Once we have worked out what is going on and found out why we are doing things - we then tend to move onto finding a better way - Principal number 3 at TMT.
Find A Better Way
Here we simply need to work out ways how:
1- They can move more.
2- Do something different- stand on the train, undertake a new type of exercise. If they do what they always do, they will get what they have always got.
Keeping a neutral posture is a nice reference point- however it is not a priority for long term spinal health. Your spine is designed to load and move. If you believe neutral spine is the most important aspect- try sitting perfectly still in a neutral spine all day or ask one of the Queens Guards units outside Buckingham Palace (who have perfect posture for all of their working hours on guard) if a neutral spine is key.
One of may favourite ways to change this is to add in some "modular sitting"- in other words changing positions every 10-20 minutes.
An example of how to do this would be
- Stand for 20 mins
Second move to a kneeling posture
You can then use a lunge position and if you are able, you can utilise a position humans have been using for thousands of years to rest in- The Squat.
If you have some space you could also utilise the prone position or what mothers call tummy time by lying flat on your stomach.
Once you have done all of these you have then "earnt your 20 minutes of sitting"
Of course space and also office politics will be an issue for some- however I do not think that in this time the "excuse" of I cant as "people will look at me funny" really fly's. Most workplaces I have ever been to or visited (including some pretty strict Military bases in the UK) are very open to reduce back pain and give their employees. Refer to my thoughts on beliefs below.
3- Think differently
As we know lots of low back pain has a huge biopsycosocial input- and the way a patient thinks about pain is a huge factor in how they will recover. As therapists we need to make sure we are not enhancing what Larimer Mosely calls thought virus’s.
“I’m in pain so there must be something harmful happening to my body."
“We can put a man on the moon, why can’t someone fix this pain for me?"
“I’m so frightened of my pain and of injuring my back again that I’m not doing anything."
“I’m staying home, not going out, I’m keeping quiet and out of things."
"My pain is worse on Monday.”
It is now understood that thoughts are powerful enough to maintain a pain state, known as thought viruses. These viruses are known to cause and enhance a low back pain experience, and likely have an effect at the whole body.
Get Off The Plinth
Our Last Principal at TMT is Get Off the Plinth
Physiotherapy is a broad spectrum of manual therapy, soft tissue mobilisation all the way through to moving around, coaching and strength and conditioning.
Once we have settled some initial pain and have created some extra movement- the patient needs to be shown how to use their body differently- but need to bear in mind that they will need to walk before they run.
For example Can someone control their pelvic tilt/ and or waiters bow before they practice full lumbar flexion. Success often leaves clues- and speaking to any expert it is essential to master the basics before high level skill is achieved.
As we say at The Movement Team “Life takes place outside of the clinic, if our treatment isn’t exactly replicating their demands and needs outside of the clinic, it will be a failure"
Yanek is Physiotherapist with has 11 years of experience, across 2 countries, including invaluable experience working in the English Premier League (EPL), military rehab centres and private clinics.