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Posts tagged ‘Low back pain’

Lower back pain part 3: Prevention

Ok, so in part 2 of lower back pain I explained a little about what a herniation is, now I want to start talking about how to prevent a herniation. First, let me go into a little more detail about what a disc is. ( read https://sports-diet-pain.com/2013/10/18/lower-back-pain/ and https://sports-diet-pain.com/2013/10/21/low-back-pain-part-2-herniation/ )

A disc is the substance between the vertebrates. It has a nucleus and a annulus. The annulus surrounds the nucleus and prevents it from coming out. The nucleus is a gel like substance, and a herniation is when the annulus breaks and the nucleus comes out ( more or less). The disc varies in size depending on the time of day. In the morning the discs are usually bigger than at night, because we have been laying down for hours and the discs have absorbed liquids. That is why in the morning we are usually taller than at night and a reason why we shouldn´t be doing flexion activities in the morning. The bigger the disc, the more stress you put on it and on your ligaments. A study estimated that disc-bending stresses were increased by 300% and ligament stresses by 80% in the morning compared to the evening (1). In another study it was demonstrated that simply avoiding full lumbar flexion in the morning reduced back symptoms (2). So first factor in preventing herniation and lower back pain, don´t do flexion activity in the morning, wait at least 30 minutes to an hour, that is usually what it takes for the disc to return to normal size.

Spine has memory. The function of the spine is modulated by certain previous activity. This occurs because the loading history determines disc hydration, which in turn modulates ligament rest length, joint mobility, stiffness and, load distribution. In simple words, when we are sitting down, we are in flexion. This means that the nucleus of the disc has moved posteriorly, and we have ¨stretched¨ the posterior ligament (3). So it would be unwise to lift things after a bout of prolonged flexion, like for example when we are sitting for a long time . Then, a second factor in preventing herniation and lower back pain, don´t lift things up after being in flexion for a long time. Meaning if you have sat down the whole day, don´t go right away and try to pick up something heavy, the changes of hurting yourself are going to increase. All you have to do is stand up, wait 5 minutes, and your changes of getting hurt will greatly diminish. This can also be said to all those that play sports like for example, basketball. When you are on the bench sitting down, you are in flexion. So it would be much wiser, if you know that you are going to go into the game, to stand up, or to try sit in a way that your back isn´t in flexion.

Too much of anything is usually bad. In a study done in 1975 (4-5) , it proved that seated work posture creates an increase in lower back pain (LBP).  Another one  in 1996 (6)  also suggested that people who sit for long periods of time have a greater risk of low back troubles (8%), but what was even more interesting is that active workers, meaning people who worked moving around or standing up, reduced their probability of getting back pain by 14% if they would sit once in a while. This suggest that variable work, and not too much of any single activity is the best thing. In other words, if your job consist of sitting down the whole day, it would make sense to get up and move around once in a while. And if your job consist of being active the whole day, it would be clever to do the opposite. So any business man out there thinking of creating their own business or ones who already have one, make your workers do VARIABLE WORK, and you will save up money in the long run.

I already said how easily it is to hurt yourself from flexing your back, how you shouldn´t pick up heavy things after prolonged bouts of flexion, how the best thing to do to prevent LBP is to do variable work, but the number one thing you should really try to avoid is FREQUENT BENDING AND TWISTING (gardening is an example of frequent bending and twisting). The U.S. Department of Labor (1982) and many more studies noted the increased risk of lower back pain from frequent bending and twisting (7-8). In this report vibration was also included, especially seated vibration. So all those power plates fanatics carefull with the vibration (7,9).

80 % of us will probably get back pain at one point or another, that´s a lot! But I´m pretty sure that if we try to avoid things I have mentioned in this blog the chances of us getting hurt will greatly diminish.

Hope you enjoyed it

References

  1. Adamas M, Dolan P. Diurnal variations in the stresses on the lumbar spine. Spine 1987,12(2):130.
  2. Snook SH, Webster BS, McGorry RW, Fogleman MT, McCann KB. The reduction of chronic nonspecific low back pain through the control of early morning lumbar flexion. Spine 1998, 23: 2601-07.
  3. Mcgill S. Low Back Disorders Evidence Based Prenvention and Rehabilitation 2nd. Human Kinetics 2007.
  4. Kelsey JL. An Epidemiological Study of Acute Herniated Lumbar Intervertebral Disc. Rheumatol Rehabil 1975:14;144-5.
  5. Kelsey JL. An Epidemiological Study of Acute Herniated Lumbar Intervertebral Disc. Int J. Epidemiol:4;197-204.
  6. Liira JP, Shannon HS, Chambers LW, Haines TA. Long-term back problems and physical work exposures in the 1990 Ontario Health Survey. Am J Public Health. 1996;86:382–387.
  7. The U.S Department of Labor Report (1982)
  8. Marras WS, Lavender SA, Leurgans SE, Fathallah FA, Ferguson SA, Allread WG, Rajulu SL. Biomechanical risk factors for occupationally related low back disorders. Ergnomics 1995 Feb:38(2):377-410.
  9. Seroussi RE, Wilder DG, Pope MH. Trunk muscle electromyography and whole body vibration. J Biomech 1989:22(3):219-29.
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Abdominal

Abdominal, I don´t think there is a more popular muscle group than this one. Everyone is obsessed with it. But why this obsession? And are they really that important?

First, let me describe what the abdominal muscle group is. The abdominal muscle group is composed of:

  1.  Rectus abdominis:  this is a muscle that goes from your sinfisis pubis, pubic crest and pubic tubercle, to the xiphoid process and costal cartilages from the 5th to the 7th (1). So in other words, this is the famous ¨6 pack¨ or ¨8 pack¨ muscle we sometimes see people have at the beach. Important note: although the muscle seems like it is divided, it actually is not. Meaning it is just one muscle, and a upper rectus and a lower rectus does not exists. (2) Thus, training the rectus for nearly everyone can be accomplished with a single exercise. So all that raising the legs, lowering the legs, and other stuff we usually see when we go to the gym, is BS. If we want to train the rectus abdominis one exercise is sufficient to activate all portions of the muscle. So a simple curl up would work.
  2. Obliques:These are the muscles which some of us see to our sides. There is an internal oblique and an external oblique. The external oblique is more superficial than the internal oblique. The upper portion and lower portions of the obliques are activated separately, meaning, here it would be useful to have an exercise for the upper portion and another for the lower portion of the obliques (2).
  3. Transverse abdominis: This is the muscle that is under the rectus abdominis. So it is quite deep inside. You cannot see this muscle. This is a muscle that became very popular especially thanks to pilates, where they would teach you to  ¨hollow¨ (drawing in the abdominal wall) to activate the muscle. Let me explain that you don´t need to hollow to activate the transverse, the transverse can be activated when you activate the other abdominal muscles. For example, imagine someone is going to punch you in your stomach, what do you usually do? You brace, which is a contraction of all the abdominal muscles. This bracing is much more effective for stability than hollowing, and this is the technique you should be using whenever you want to pick up something heavy (3,4). To demonstrate this, let us do an experiment. Sit on the edge of a chair and hollow (draw in the abdominal wall), and while maintaining that position try to get up. Then sit on the edge of a chair again, but this time brace (just a little), and  try to get up. You see the difference?

Ok, now that we know a little about the ABDOMINAL, let´s try to clear up some of the myths that exist.

  1. First myth: ¨By having a strong abdominal you won´t get back pain ¨ or¨ you have back pain because of your weak abdominal or because of your weak core¨. That is the biggest BULLSHIT there is (and something I used to say, I´ll admit it) !! The only thing that consistently prevents low back problems is exercise (5-6). Doesn´t matter what you do, just move and the chances of having back pain will diminish. And when you have back pain, specialized exercises like targeting the ¨core¨ will do no better than for example going for a walk (7-8).
  2. Second myth: ¨Do abdominal exercises to lose the fat¨. If you are overweight, you want to burn as many calories as possible. Doing curl ups or other abdominal exercises doesn´t really burn up that many calories. And even if doing curl ups would burn a lot of calories, it probably wouldn´t burn the fat that you have around your belly. So if you are overweight you should be doing more important things than ¨curl ups¨.
  3. Third myth: ¨Do a lot of abdominal exercises and you will get the 6-8 pack¨. We all have the 6 or 8 pack, the problem is that there is a lot of fat that is preventing us from seeing it. Lose the fat and you will see the abdominal muscle. This doesn´t mean you should not be working out your abdominals, of course you should! But you should not be obsessed with them. The best way to get a 6-8 pack is eating properly and doing exercise. Most people who have a 6 pack is thanks to the fact that they have an incredible active lifestyle that makes them burn a lot of fat. They have that 6 pack because of their way of life, not because they exercise with that specific goal to have a 6 pack.

So in conclusion, the abdominal muscle is important and everyone should train it but you should not be obsessed with it. Everyone has a 6-8 pack, the problem is that it is hidden under our ¨fat¨. Burn that fat and you will see that 6 pack. There is no point in trying to train the upper and lower abdominal because, as I have stated before, there is no such thing. What you feel when you raise your legs is another muscle called the psoas iliacus. A simple curl up is good enough to activate the whole rectus abdominis. With all that said, there are still exercises that target and make the abdominal work in a much more effective way than the simple curl-up or sit-up, which by the way I wouldn´t recommend anyone doing. That is something I will talk about in my next blog, why you shouldn´t be doing sit-ups and what exercises are the most effective for the abdominal. Stay tuned and until next time.

References

1.Mcgill S. Low Back Disorders: Evidence Based Prevention and Rehabilitation. Human Kinetics. 2007.

2.Mcgill S. Ultimate Back Fitness and Performance, Fourth Edition. Backfitpro Inc. Waterloo, Ontario, Canada 2009.

3.Brow S, McGill SM. Transmission of muscularly generated force and stiffness between layers of the rat abdominal wall. Spine 2009, 34(2): E70-E75.

4.Kavcic N, Grenier S, Mcgill S. Quantifying tissue loads and spine stability while performing commonly prescribed stabilization exercises. Spine 2004. 29(20):2319-29.

5.Kavcic N, Grenier S, Mcgill. Determining the stabilization role of individual torso muscles during rehabilitation exercises. Spine 2004. 29(11): 1254-65.

6.Bigos SJ, Holland C, Webster JS, Battie M, Malmgren JA. High-quality controlled trials on preventing episodes of back problems: systematic literature review in working-age adults. Spine J 2009 Feb;9(2):147-68.

7.van Middelkoop M, Rubinstein SM, Verhagen AP, Ostelo RW, Koes BW, van Tulder MW. Exercise therapy for chronic nonspecific low-back pain. Best Pract Res Clin Rheumatol.2010 Apr;24(2):193-204.

8.Mannion AF, Caporaso F, Pulkovski N, Sprott H. Spine stabilisation exercises in the treatment of chronic low back pain: a good clinical outcome is not associated with improved abdominal muscle function. Eur Spine J.2012 Jan 24.

Pain part 2 – Does bad posture cause pain?

The other day we saw that pain is very complex and that in most cases it´s produced in the brain. So, if it´s really produced in the brain, does posture or movement really matter? We have all gone to the physical therapist or doctor and have heard that ¨your back pain comes because you have too much of a curve in your back¨, or ¨your back pain or shoulder pain comes because of your forward head posture¨ or ¨your knee pain comes because you have too much of a pronation on your foot¨. Hell, I´ve done it, I´ve been saying that to my patients for years because that is what was taught to me.

Up to last year I had a client, XG, who always came to me because he had back pain. I would always tell him that his back pain was coming because of his posture. He had a forward head (still does) and a big lordosis (inward curve) in the lower back .I tried to correct his posture, I gave him exercises to do at home, I stretched him, I did everything you could imagine but his posture hasn´t really changed but guess what, his pain has, it´s gone!!

So what I´m basically trying to say is that there is no consensus on supporting a biomechanical (and posture) model of pain (1-10). Because:

• Postural and structural asymmetries cannot predict back pain and are unlikely to be its cause (1).

• Local and global changes in spinal biomechanics are not demonstrably the cause of back pain (1).

• A postural structural biomechanical model is not suitable for understanding the causes of back pain (1).

This is so because postural structural asymmetries and imperfections are normal!! The body has surplus capacity to tolerate such variation without loss of normal function. That is why there is little scientific evidence to show that posture will cause pain (2-5). If posture was a factor of pain how come you see thousands of people around with bad posture with no pain and thousands more with ideal posture in a lot of pain? That just shows that there is much more to pain than just posture.

This is not meant to deny that there is a correlation between pain and certain postures, but that this association is neither sufficient nor conclusive to justify our efforts to dictate people’s posture and movement. But what we do know for sure is that there is no ‘ideal’ posture, and any posture if maintained for too long will result in dysfunction, and maybe pain. The key is movement.

To end this article and the topic of posture and pain, and to confuse people even more, I will say that there actually is potential harm in  “addressing” the unsubstantiated claims of bad posture. Things just as: focus on “bad” movement or “bad” positioning have the potential to sensitize the individual into believing that a benign (wrong) positioning is in fact something that represents a threat. And as we saw yesterday in the video, pain is the response to threat, either real or perceived, and how we view our environment and ourselves within that environment can positively or negatively affect that threat response. So by addressing things that don’t have evidence to support them (bad posture), we are actually increasing the chance that an individual might have the very real experience of pain. We are creating a self-fulfilling prophecy. That is real harm – and it is evidenced (2-5).

I will finish by quoting some of Lorimer’s famous quotes and with a link to a video that demonstrates the tricks the mind can play on us.

Favorite Lorimer Quotes

  • “Pain is very complex.”
  • “We can’t treat every pain patient with a simple solution.”
  • “The best way to get rid of chronic pain is to chop the person’s head off.”
  • “As soon as you interact with the patient, you are in their brain.”
  • “Always do more today than you did yesterday.”

http://www.youtube.com/watch?v=sxwn1w7MJvk

P.S In my last post I said that you can have an injury without having pain. Some of you didn´t believe me, which is normal, so references 7-12 demonstrate just that.

Also, those that have been following me may be asking themselves why I still  haven´t talked about how to deal with pain. The simple answer is that I first wanted you guys to really understand what pain is and change the way you think about it. With these 2 posts maybe you haven´t really understood it yet, but I probably made you look at pain from a different perspective. Now that we have this different perspective, in my next post I will finally talk about how to ¨deal¨ with it. Hope you liked the article, until next time.

Bibliography

1. Lederman E. The fall of the postural-structural-biomechanical model in

manual and physical therapies: exemplified by lower back pain. J Bodyw Mov

Ther. 2011 Apr;15(2):131-8. doi: 10.1016/j.jbmt.2011.01.011

2. Loeser JD, Melzack R. Pain: an overview. Lancet. 1999 May
8;353(9164):1607-9.

3.Moseley, G. Lorimer. Reconceptualising pain according to modern pain
science. Physical Therapy Reviews 2007; 12: 169–178.

4.G Lorimer Moseley. Teaching people about pain: why do we keep
beating around the bush? Pain Manage. (2012) 2(1), 1–3.

5.Melzack R., Katz J. (2013), Pain. WIREs Cogn Sci, 4: 1–15.

6. Moseley GL. Pain, brain imaging and physiotherapy–opportunity is
knocking. Man Ther. 2008 Dec;13(6):475-7.
7.Jensen MC et al. Magnetic resonance imaging of the lumbar spine in people
without back pain. N Engl J Med.1994 Jul 14;331(2):69-73.

8. Sher JS et al. Abnormal findings on magnetic resonance images of
asymptomatic shoulders. J Bone Joint Surg Am. 1995 Jan;77(1):10-5.

9.Melzack R, Wall PD, Ty TC. Acute pain in an emergency clinic: latency of onset
and descriptor patterns related to different injuries. Pain. 1982
Sep;14(1):33-43.

10. Boden SD, Davis DO, Dina TS, Patronas NJ, Wiesel SW. Abnormal magneticresonance
scans of the lumbar spine in asymptomatic subjects. A prospective
investigation. J Bone Joint Surg Am. 1990 Mar;72(3):403-8.

11. Kleinstück F, Dvorak J, Mannion AF. Are “structural abnormalities” on
magnetic resonance imaging a contraindication to the successful conservative
treatment of chronic nonspecific low back pain? Spine (Phila Pa 1976). 2006
Sep 1;31(19):2250-7.

12. Bhattacharyya T, Gale D, Dewire P, Totterman S, Gale ME, McLaughlin S,
Einhorn TA, Felson DT. The clinical importance of meniscal tears
demonstrated by magnetic resonance imaging in osteoarthritis of the knee. J
Bone Joint Surg Am. 2003 Jan;85-A(1):4-9.

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