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BACK TO BASICS
with Jenny Branigan

*Please Note*
If you are suffering from back pain you should talk to your Chartered Physiotherapist or GP before undertaking any exercises or treatment.

1. General anatomy of the Spine and Low Back
All joints need motion to stay healthy - joints are designed for movement; movement is their purpose.

In our spine we have:

  • 5 vertebrae in the neck or cervical spine
  • 12 in the upper or thoracic spine
  • 5 in the low back or lumbar spine
In between each of these vertebrae we have a disc:
  • It is like a small cushion for shock absorption
  • Discs are 70% water
  • Discs stay healthy through motion, which pushes out toxins and draws in nutrients much like a sponge.
  • Discs sit anchored in between vertebrae. Cartilage endplates along with a system of ligaments hold each disc in proper position. Therefore, discs cannot 'slip' out of place.

Two parts to a disc:
  • a protective circular outer layer (Annulus Fibrosus) and a gel-like center (Nucleus Pulposus)
  • If the outside annular wall weakens, cracks, or opens the nucleus may leak out from the disc.
  • Discs get bigger as you go lower in the spine, so the discs in the low back are the biggest as they have to support the weight of the upper half of the body.
  • When posture worsens, normal motion between the vertebrae is lost and the discs become damaged
  • As we age the discs shrink, dry out, and cracks can form in them but that's normal
  • Problems with the discs can result from a few things: a crack in the annular wall with or without the nucleus pushing into it, or a herniation where the nucleus pushes right out through the outer annulus.
Discs absorb stress:
Imagine the way that a disc absorbs stress and pressure is similar to a tube of toothpaste. Squeezing the tube places the contents under pressure. If the tube encasing the paste has a weak spot or a hole, the paste leaks out through the opening. This is like what happens with a bulging disc or a herniated disc. Fortunately, the majority of herniated or ruptured discs do not require surgical intervention.

Imagine biting into a doughnut - the jam squirts out the back of it! The disc bulge can happen in a similar way. With disc pressure, the outer layer tears and the central nucleus pushes out to the side or to the back. If it pushes out enough, it can press on a nerve / spinal cord. Some types of body movement create more disc pressure such as jumping or lifting a heavy object.

Facts about Low Back Pain (LBP)
  • 70-80% of population will get LBP at some stage in their life
  • 60% of those will suffer a recurrence
  • The best thing you can do to prevent LBP is to never get it in the first place!
  • Look after your back - most people lift and twist and never consider their backs before undertaking such tasks
  • Prolonged postures can cause LBP
  • LBP can cause referred pain into the buttocks, legs and feet (happens in 35% of cases). This referred pain is often mistaken as sciatica, which is incorrect.
  • True sciatica is only seen in approx 2% of cases, more common in males, peak age 40s.
  • 90% of LBP will settle within approx 6 weeks.
  • We are 2cm taller in the morning than in the evening - the discs in the back are like cushions - during the day as they are compressed from our weight, water is pushed out of the discs and makes us smaller by the evening!
Signs and Symptoms of Different Types of Low Back Pain:

Simple non-specific low back pain:
  • Onset generally age 20-55 years
  • Low back and base of spine region affected, buttocks and thighs
  • Mechanical pain - varies with physical activity and time
  • Patient feels well otherwise
  • 90% recover in up to 6 weeks
Nerve Root Pain:
Nerve roots exit the spinal canal through small passageways between the vertebrae and discs. Pain and other symptoms can develop when the damaged disc pushes into the spinal canal or onto the nerve roots.

  • Leg pain in one leg, often without low back pain
  • Pain goes to foot or toes
  • Numbness or pins and needles in the same area of the foot / toes
  • Irritated nerve signs
  • Can get weakness or sensation change
  • 50% recover within 6 weeks
Sciatica:
  • Pressure on one or several nerves that contribute to the sciatic nerve can cause pain
  • Usually one side only is affected
  • People often think they have this when in fact the just have referred pain - 2% only will have true sciatica
  • Frequently associated with a lumbar herniated disc
  • Can also feel burning, tingling, and numbness that extends from the buttock into the leg and sometimes into the foot.
Disc Degeneration:
  • Happens naturally as we all age
  • Seen on xray as a loss of disc space height
  • A lot of people go for xray when they have pain and are told they have disc degeneration, which is often blamed for causing their pain. That is inaccurate.
  • Can have disc degeneration on xray without any pain at all
Bulging Disc:
  • Commonly referred to, incorrectly, as a "slipped disc"
  • Dull or sharp pain, muscle spasm or cramping, sciatica, and leg weakness or loss of leg function
  • Sneezing, coughing, or bending usually aggravate the pain
  • Rarely bowel or bladder control is lost, and if this occurs, seek medical attention at once.
*Red Flags*
LBP with these serious symptoms should NEVER be ignored:
  • Age less than 20 or greater than 55 years
  • Violent trauma - fall or car crash
  • Constant pain, not relieved by position or rest
  • Upper spine pain
  • Feeling unwell
  • Losing weight rapidly
  • History of cancer
  • Widespread pins and needles and numbness
  • Loss of control of bladder or bowel (rare)
  • Pins and needles in genital area
  • Widespread leg weakness or problems walking
If you have some of these symptoms the Chartered Physio will send you immediately to your GP for tests - xrays and blood tests (ESR)

LBP in Sport:
  • Most common in sports with repetitive actions - rowing, hockey
  • Rugby players - position dependent. Front rows and hookers are most at risk
  • Lots of pressure on front row players in the scrum - have your own team and the opposition pushing your spine from each end
Tend to have them play on despite the pain, they are desperate to keep their place on the team / play in the final / think they'll never develop a serious problem with it as they are young.

LBP in pregnancy:
  • Common - approx 50% will get it
  • Can happen at any stage but most commonly in 3rd trimester
  • Hard to predict who will get it
  • Increased risk if:
  • Previous history of LBP
  • Previous LBP during pregnancy
  • Advanced maternal age
  • When you have given birth on multiple occasions
Why does it happen:
  • Enlarged uterus changes weight distribution
  • Get increased pelvic tilt forwards
  • Weakening of stomach muscles offers no protection
  • 3rd trimester worst time for it - ligaments relax in pelvis in preparation for the birth
Take care with the exercises you do:
  • No sit ups - can cause separation of the abdominal muscles
  • Yoga stretches strengthen the pelvis and back while also encouraging women to maintain postures, which protect their spine during pregnancy.
  • Pilates focuses on the abdominal muscles and pelvis floor muscles, teaching women how to support the weight of the baby while protecting their lower back and pelvis.
  • Walking
  • Exercising in water is ideal for pregnant women as the buoyancy of water makes the body lighter thus allowing more exercise with less strain.
  • Can get support belts to help
LBP at Work:
On average we spend 7-8 hours per day at work.
For some this is at a desk with frequent movement to the printers, to other colleagues, out for lunch.
For others it can mean hours at a time on the road or lots of travel.
Unfortunately there are high numbers of workers commuting long hours to and from work daily, sitting in traffic, getting frustrated behind a long tailback - all of which doesn't help the nerves, never mind your backs.

One major risk factor for the back is lack of movement
Those most at risk from occupational side of things include those who drive for a living, especially taxi drivers and those who do lots of heavy physical work.

There is no "perfect posture for all time"
A dynamic posture or one with frequent changes in position is the best way to reduce stress and redistribute pressure related to long duration static postures.
Work can be sustained for longer times without causing harm if the person is working in a neutral posture.
A more common one in recent times is the phenomenon of eating a sandwich at your desk or not getting around to it at all.

When the back is in a prolonged posture, the soft tissues gradually move to accommodate that area. Think of falling asleep on a pillow corner and waking with a dent in your face - called CREEP.
If you are driving for a long period and then get out and lift something out of the boot, you have stretched the ligaments of the low back during the drive, they have not recovered yet and you stress them further by lifting.

Choose a comfortable chair for the user to sit in, adjustable height, comfortable to sit on and has a good backrest that provides lumbar support. Studies show that the best seated posture is a reclined posture of 100-110 degrees NOT the upright 90 degree posture that is often portrayed. In the recommended posture the chair starts to work for the body and there are significant decreases in postural muscle activity and in intervertebral disc pressure in the lumbar spine.
Erect sitting is NOT relaxed, sustainable sitting, reclined sitting is.

Incorrect lifting technique:
  • Never bend the back when lifting
  • Manual handling courses teach people to lift with the knees bent to take the strain off the back.
  • Assess the weight of something you need to lift - don't be afraid to ask for help with it
  • Common to see people presenting with pain when they have lifted an object quickly without gauging whether they were able for the weight of it or not
Posture:
  • When you sit or stand correctly you are using your muscles to keep you upright The stronger these muscles the easier it is.
  • The problems come when you slump and your back and tummy muscles become stretched and weak, that's when you feel the little twinges of pain begin.
  • So check your posture, use the muscles you have to sit / stand up correctly
  • Change your position regularly if you can.
Treatment:
  • Bed rest, avoiding all movements - NO GOOD! Outdated!
  • Must keep active - go to work, go out walking, go about your daily business but always within your pain-free limits
  • Early diagnosis and intervention
  • Don't necessarily need to visit GP unless pain relieving medication if required
Advice on what you can/can't do is vital:
  • Avoid long drives
  • Avoid heavy lifting
  • Avoid high heels / very flat shoes
  • Frequent postural changes during the day
  • Sleeping position important - no lying on tummy!
  • Ice vs Heat
  • Appropriate exercises for you
  • Care using heavy laptop bags on one side - spread the load!
DRUGS:
  • Recommend paracetamol in first instance
  • Anti-inflammatories eg difene
  • Muscle Relaxants
  • There are some contraindications - if you have asthma or an ulcer you may not be able to take anti-inflammatories
  • Never take medication that someone else has been given for their back - it may not suit you
  • Note that medication masks the pain - this may allow you to do more damage to the injured area. Often see sports people eating tablets just to get onto the pitch and then they pay for it later.
Internet / Google Self Diagnosing:
  • Not accurate in many cases
  • May miss more sinister signs
  • Exercises need to be tailored to the individual problem - you may do exercises that are inappropriate for your condition and make things much worse.
SURGERY
  • The last straw. Not to be taken lightly.
  • Sometimes people are eager to get it done for a "quick fix" as they are not willing / motivated to do what is necessary to settle the pain and prevent it in the future. Not a good option for this group.
  • Only 2-5% will have to go down this route
  • Only considered if the pain does not resolve after months of conservative treatment with no change and if the pain is affecting your quality of life.
  • In some cases, if there is urgent pressure on the nerve or spinal cord that will not settle itself, surgery may be recommended.
  • Every patient has the right to decline surgery or obtain a second opinion.
Certain spinal symptoms may require surgical consideration:
  • Loss of bladder and bowel control
  • structural instability
  • tumor
  • infection
  • deformity
  • progressive neurological deficit
  • unrelenting pain that cannot be controlled by conservative means
Other options:

PILATES
  • Great overlap with Physio - Jenny's an instructor
  • Very popular
  • Great for stability of postural muscles in abdomen and around shoulder blade
  • Recommended for those with chronic low back pain
  • Preventatively done now with sports teams
YOGA
  • Improves flexibility
MASSAGE
  • Can help to relieve muscle spasm
ALEXANDER TECHNIQUE
  • Tackles posture and poise
  • Lots of musicians use these techniques
Alternative Therapies
  • Always make sure that they are university trained in their speciality.
  • Don't trust just anyone with your back
  • A part time course is not enough training.
Other points to Note:

FEET AND SHOES:
  • Sometimes the problem can come from flat feet - a biomechanical assessment will usually be included in the Chartered Physio's assessment of the problem
  • High heels not recommended during an acute flare up - tilts the pelvis forward which pits more pressure on the low back
  • Trendy flat ballet pumps and Ugg boots give no support which can cause increased pressure on the back
  • Trendy trainers are often very flat with no arch support in them - again can cause increased pressure on the back
BAGS
  • Spread the load
  • Schoolbags are a common cause of pain in schookids
  • During a flare up - avoid shoulder bags on one side - makes you lopsided and can increase muscle spasm
  • Laptop bags on one shoulder are a disaster as they are very heavy
BEDS
  • Sleeping position is important
  • Lying on your tummy is not good for your back
Better positions:
  • Side lying with a pillow between the knees
  • Lying on your back with a pillow under the knees
  • Changing the sleeping position often fixes the problem
MBT's
  • Not for everyone, not a cure-all
*Please Note*
If you are suffering from back pain you should talk to your Chartered Physiotherapist or GP before undertaking any exercises or treatment.