From: DrSquat@aol.com Date: Thu, 11 Jan 1996 Subject: Info on Back Problems Here's one from my ISSA colleagues...Dr. Arria was the chief DC for the US Olympic team in the 1984 LA Olympics. His back article, I believe, will be helpful to all who subscribe. Fred Hatfield, Ph.D. Dr Squat Dealing With Low Back Pain: Nerve Impingement and Inflammation Sal A. Arria, D.C., MSS, & Charles I. Staley, B.Sc.,MSS International Sports Sciences Association Editor's Note: This article was adapted from "The 5 Step Back Solution," a self-help videotape produced by the American Institute of Health Education Note: If you have back pain, always start with an accurate diagnosis from your chiropractor or physician. Make sure you ask him to explain what's wrong, and then listen carefully to his recommendations. Learn as much as you can about your condition. Low back pain is the most frequent cause of missed work after the common cold- it's been estimated that over 90 million people suffer with this debilitating condtion. However, with all the knowledge and diagnostic tools that we have available to us today, there is no reason that back pain should continue to plague so many people. The key to managing low back pain starts with the decision to take an informed, active role in maintaining your health. Your back needs a little maintenance every day- even when you don't have pain. When you visit with your doctor, you might spend 15 minutes in an office visit. However, you spend 24 hours a day, 7 days a week living with your back. Treatment and therapy are important, but it's what you do for yourself when you're not having treatment that is most important to help you live free from re-occurring back pain. Nerve Impingement Nerves can become impinged or pinched by the disks, vertebrae, or swelling of the surrounding soft tissues. When a nerve is pinched, the muscles of the back can go into spasm, and the pain can radiate away from the spine. There are three degrees of radiation: First degree, which is when pain radiates to the butt; second degree, which involves pain radiating to the knee; andthird degree, which is when pain radiates to the foot. When a nerve becomes damaged, the muscle that it supplies (or innervates) withers or atrophies because of the lack of nerve supply. If pain radiates down the leg, or if you have numbness, tingling, or loss of muscle function, seek medical intervention immediately-the longer you wait, the greater the chance that you'll have a permanent injury. Reducing The Inflammation The first step in addressing back pain is to "put out the fire." Inflammation is often the result of the joints, nerves, or soft tissues of your back becoming irritated, raw, and swollen. According to a recent government study (AHCPR), the recommended initial medical treatment of choice is usually an oral anti-inflammatory and ice. Exercise caution however, because some people can't tolerate any type of anti-inflammatory medication. Check with your physician before you use any drug. While using an internal anti-inflammatory, you should also use an external anti-inflammatory, namely ice. Flexible gel packs are best, but crushed ice in a "zip-lock" bag works well also. Crushed ice works particularly well for people who weigh over 200 pounds. Make sure that if you use crushed ice, that it's really smashed up into a fine pieces-otherwise it's like lying on rocks. Don't cover it with a towel because it just won't penetrate deep enough to work. Instead, use a zip-lock bag. Ice is cold and after a minute or people usually want off! However, the immediate pain of the ice is worth the long term relief you'll get from the reduction of inflammation and swelling. Ice has to be cold, really cold to be effective. Imagine the thickness of a t-bone steak and how cold you would need to get one side to feel the effect through the other side. That's about the thickness of the your back. The key to using ice is staying mobile and flexible. One side effect of cold is that it tends to make you a little stiff, so...stretch! Do knee to chest and pelvic rock stretches while lying on the ice. This is called cryokinetics, or "movement on ice." Not only does it keep you from stiffening up but it literally pumps swelling or inflammatory edema out of the low back as you stretch. Sidebar: Basic Spinal Anatomy and Physiology Our spines are composed of 24 moveable segments called vertebrae. The primary functions of the vertebrae are to protect the spinal cord, and to give the upper body the structural support necessary to stand. The following three points are important to understand with respect to spinal function: * Each vertebrae is designed to move freely and independently of each other. * There are disks between each vertebrae that provide a cushioning or shock absorbing function between the bones. The disks also provide space between our vertebrae which allows room for the nerves to exit from the spinal cord. * The nerves leave our spine through tiny bony openings called foramen and then travel to all parts of the body. Step 3: Increase Muscular Flexibility Once the vertebrae have been specifically mobilized, it's time to stretch the muscles of the low back and hamstrings. The best time to start is first thing in the morning, before you get up. Do a few knees to chest and pelvic rock stretches (please see sidebar) before your feet hit the floor. Then, take a hot shower and stretch. As simple as it sounds, this technique has helped hundreds of patients who have suffered for years with re-occuring back pain. Professional and Olympic athletes realize the importance of stretching and flexibility, so use the techniques they use to stretch and loosen up first thing in the morning, and then multiple times during the day to prevent unnecessary pain or injury. We recommend (5) 2 minute stretches during the day rather than one, 10 minute session because you usually stiffen up throughout the day from prolonged sitting or standing. The following stretches should take priority in your program: KNEE TO CHEST stretches specifically stretch the muscles of the low and mid back, buttock, and hamstrings. The key to knee to chest stretching is to relax before beginning to pull. Gently, clasp your hands just below your knees and pull with your arms, relaxing your low back. Hold for three to five seconds, then release. Remember, start and end this stretch with your knees bent. It takes the stress of the low back. HAMSTRING STRETCHING is a critical factor in reducing low back pain. The hamstrings (muscles in the back of the leg) connect to the bottom of the pelvis. If they are tight it will inhibit your ability to flex or bend forward, thus putting most of the load of bending on the low back rather than dispersing the load and leverage between the hamstrings, gluts (butt muscles), hips and low back. CAT STRETCHES really stretch the muscles and joints of the low back, so start off easy at first. Again, relax, start on your hands and knees with the elbows locked, and then gently allow the low back to sag into an arch (like an old horse). Hold for just a two to three seconds and then press your low back upward (like an angry cat) and hold for 2-3 seconds. Then sit back on your legs and stretch your arms outreached forward, again really relaxing the muscles of the back, butt, and legs. Hold for about 5 seconds then return to the starting position on your hands and knees and repeat several times. Step 4: Pay Attention To Your Posture We spend most of our lives with our bodies in the three basic positions: Sitting, standing, and sleeping (we have covered these topics in more detail in past M&F articles). Let's cover them one at a time: * Sitting: If you were to take a survey of people that suffer with back pain, you would find that nearly everyone sits far too much. Sitting increases the pressure in the back nearly two times your body weight. So if you're a 120lb secretary you have about 240 lbs of pressure in your low back. You probably sit and drive home after spending a long day sitting at work and then sit for dinner. Now, your back is hurting big time so you sit in front of the t.v slouched! Do that 7 days a week and you wonder why you still have back problems! Even after you saw your chiropractor for an adjustment, your massage therapist for a massage, your physical therapist for ultrasound and heat, and finally your physician for pills. It couldn't be more obvious: don't sit so much without moving. If you can, at work take a few short breaks on the floor, lie down and stretch then hit the floor at night when you come home instead of the couch. As we stand during the day, the muscles of our back become fatigued or tired. Especially by the end of the day, we have a tendency to round or hunch forward, This poor posture puts an unnecessary load on the low back because the weight and leverage of the upper body rounding forward puts a constant stress on the low back. When you're standing, don't lock your knees and round forward. Instead, spread your legs and press forward with an arch in your low back- the same position you'd use when squatting. Lean on an arm if you can- it helps take some weight off the muscles of the back. When you're lifting, bend your knees, but it's equally important to keep the weight that you're lifting as close to you as possible (please see sidebar). Don't rotate or twist. Square off to what you are going to lift. It doesn't take much weight to cause an injury. Never outreach, lift and rotate: It's the easiest way to tear or rupture a disc because of the forces and leverage on the small support ligaments of the spine. They just can't take it. Also, prolonged standing with your weight shifted on one leg or another creates an uneven, lateral, or side bending of the spine. This really loads the tiny joints of our back. An example of this concept is a new mother. It's tough carrying a baby around without putting them on one hip, but try to switch sides often, and keep the baby close to you. Don't exaggerate the sway of your back by letting your tummy hang forward. If you stand on a hard surface like concrete all day, the cumulative effect of compression and the constant pounding and jarring of your spine when you walk with hard shoes is just another variable that can contribute to your back pain. Assess the surface and work place you stand at all day. NIKE AIRŪ shoes do an incredible job stabilizing the foot and cushioning the impact on heel strike. Nike has a wide variety of AIRŪ shoes worth trying. They're designed to really take the shock out of each step. Nike designs their shoes to protect and support athletes who make millions of dollars for playing sports. The same technology and material they use can help us combat the effects of pounding and compression that we have to go through walking and standing all day, every day on hard surfaces with hard shoes. It's just another variable that can cause back pain that is easily remedied. * Sleeping: First, don't sleep on your belly. Prolonged hyperextension from sleeping on your stomach causes the low back joints to jam together and it definitely contributes to back pain. Try to sleep on your back with you knees bent, or if you sleep on your side and have a small waist, use a pillow under your waist to keep the plane of the spine horizontal with the bed. Don't be afraid to use lots of pillows around you - not to prop you up, but to support you in an oblique or almost on your side position. Select a mattress that's not too firm but not too soft. Rotate and turn your mattress every couple of months- if you can't afford a new mattress, use a piece of plywood between the mattress and the box spring for added support. We spend almost one third of our lives in bed, so if you wake with pain, the first thing to do is to replace your existing mattress! Step 5: Strengthen Your Back And Abdomen The back is supported on the outside by muscles, and on the inside by ligaments and tendons. They must be exercised to strengthen them, but make sure you follow the previous four steps before attempting to strengthen your back. Check with your doctor and ask him which exercises you should or shouldn't do. If you try to strengthen your back or abdomen without becoming flexible first, you really stand a chance of straining your back. Think about it. If your back muscles are tight and you try to do an abdominal exercise which requires forward flexion or bending of the trunk, you'll strain or sprain your back. Now comes the work. The bottom line is, if you have back pain, you must eventually work on strengthening the surrounding muscles and ligaments that support your back and trunk in order to keep your symptoms from reoccurring. Just a few minutes a day will make a big difference. The abdominal muscles provide approximately fifty percent of the support for the back. You must tighten up your tummy. The area between the rib cage and the pelvis is called the trunk. Like a giant redwood tree, you'll never see one standing with one half of a trunk! Your trunk is composed of two major muscle groups, the abdominal muscles and the muscles of the back. The effectiveness of abdominal exercises is enhanced by training consistently and having good form or technique. Exercise the abdomen a few times a day, morning, noon, evening. Lie on the floor instead of sitting on the couch at night watching t.v. Then on every commercial do a few knee to chest stretches and ab crunches. It really works! Consistent, moderate training is the key to great success without a lot of effort or time. Statistics tell us the average person watches two to three hours of t.v. a day. So hit the floor at night and start to strengthen those abdominal muscles while you're watching the tube, talking on the phone, or reading to your kids. Try to remember to tighten your abdomen throughout the day as you stand, work, or drive. A simple thing like keeping your abs tight really does make a big difference because it helps take the load off the back during the day. In the case of women, especially after having a baby, the abdominals are weak. They took nine months to get out of shape and they'll take a few months to come around. If you just let them go, you'll be prone to back pain. For men, the beer belly that you're working on reducing sets you up to having back pain because it pulls the spine into a sway and offers no support for your back. Until your abdominal muscles become strong enough to support your back, use a belt or support. Belts increase the abdominal support by providing support from the front of the spine. If you have to lift for a living, or if your job necessitates loading, bending, carrying, standing reaching all day, then use a belt. I'm sure you've seen workers wearing them. Over the years we've recommended belts with great success. Recognize that using a belt isn't intended to replace your abdominal strengthening program, but rather as a support until your abdominal musculature gets strong enough to carry the load. Even when your abs do get strong, it's o.k. to use a belt if you have a job that requires prolonged heavy lifting. After all, football players, powerlifters, bodybuilders, and weightlifters have used them for many years to protect their backs during heavy training or competition, and they usually have very strong abdominals. Keep the belt loose when you're not lifting, then synch it down tight when you have to carry or lift heavy objects. During the acute phase (the first week or so) of back pain, we recommend the use of a belt or support most of the time except sleeping or lying on ice. While you're driving, sitting at work, or if you have to return to work when you're still in pain it's o.k. to use a belt most of the day. We can't stress it enough: the constant aggravation created by not having abdominal support is a significant reason for an unnecessarily prolonged recovery after an injury.