Back Health Survey Discussion: Risk Factors for Low Back Pain

The discussion points here respond to the questions from yesterday's post, entitled "Back Health Survey."

1. How frequently do you perform moderate-high intensity exercise? In general, back health is improved as you do regular exercise, especially cardio exercise and strength training. However, it is important not to injure your back during exercise with excessive, early high intensities or uncontrolled bending/twisting.
   
2. How many hours/day do you sit on most days of the week? Likely, you have minimal control over how much you sit at work, but the rest of your day is yours to stand and walk more! Too much sitting puts your spine in a rounded or flexed position for long periods of time (unless you practice perfect sitting posture with additional lumbar support). Also, sitting does not promote cell growth and circulation as well as standing/walking, so it can lead to spine issues later in life.

3. How often do you perform back strengthening exercise or core strengthening? I recommend you do this at least 2-3x weekly, even if only for 5 or 10 minutes each time. Good back strengthening includes back extensions (backwards bending or arching of the back). Abdominal strengthening is also good (crunches are better for your back than full sit-ups). Core strength exercises of all varieties are great for your spine health, as they strengthen the deep abdominal and spine muscles, which will give natural spine support when you do strenuous daily tasks.
   
4. What is your usual sitting posture? First, check the chair you sit in to ensure it is ergonomic. Then add a lumbar roll (rolled up towel or round pillow) behind your low back. Sit at the back of the chair, then add your additional lumbar support.
   
5. What is your present weight status? Extra weight puts more strain on all your joints, including your spine.

6. How many episodes of major low back pain have you had in your lifetime (enough to limit your usual functional activities)? Low back pain comes in repeating episodes, so if you have had several, you likely will have more in the future. But it is not too late to get treatment, of which Physical Therapy can help significantly! Not only will you learn exercises but also things to avoid and how to self-manage your symptoms.

7. How far down did your low back pain symptoms radiate? Symptoms that radiate further down the leg are worse than those in the back only. That is because nerve(s) are being pinched in the spine, causing the symptoms to shoot downward. The key to treatment is to find what eliminates the leg symptoms and moves them more centrally, to the spine (AKA centralization).
   
8. How did your low back pain resolve? Your risk of future back pain is increased if your prior back pain has never resolved or has become chronic. In this case, you and your medical team have not yet found the ideal treatment plan, so all options should be considered, perhaps multiple times.

9. How often do you practice proper body mechanics during daily activities (such as squatting instead of bending, avoiding twisting, and good lifting techniques)? This may be the single most important factor to decrease your risk of future low back injury! Simply begin to implement body mechanics changes in your daily life. Soon they will become habitual.

10. How much heavy lifting do you regularly perform? Heavy lifting can increase your risk for back pain unless it is always performed correctly (spine straight and using the legs only to do the work of lifting).

11. How often do you participate in high risk sports/activities (such as skiing, skydiving, skateboarding, 4-wheeling, etc)? Trauma obviously can cause major back injuries or worse (becoming paralyzed or even death), so proceed only with extreme caution, and practice utmost safety measures.
   
12. How often do you perform standing forward bending exercises (such as touching the toes)? This is one of the single worst exercises you could perform. Your spine does not need to be stretched into a forward bent (flexed) position. What is your reason for doing this exercise? If it is for hamstrings stretching, use an alternate technique. If you do this out of habit or from something you learned in your past, change it because this can majorly damage your spine.

Exercise Ball Chairs: Yay Or Nay?

I do recommend using an exercise ball chair if you have a desk job. It forces you to think about and practice improved posture. It also can help to strengthen your core (abdominals and back) muscles.

Exercise balls are beneficial for improving core stability and strength. They can be used for a variety of exercises and can easily be incorporated into your workout routines. You can find many exercise DVDs with specific theraball programs. The benefit of adding a chair to your exercise ball is that you can keep it at your desk or work station and potentially use it instead of your usual desk chair. Some exercise ball chairs have a little back support, but likely you will not lean against it; it is comparable to sitting on a stool. The chairs also have wheels, like most desk chairs.

The main downfall of the chair is that it may not be high enough for your desk. If that is the case, it is better not to use it. Good posture should be maintained while you are sitting at work, which means you need an ergonomic work station. The largest theraballs I have seen are 80-85 cm, which are appropriate for taller individuals. Some ball chairs may have a higher base, which could bring you up to the appropriate sitting height for your desk/keyboard. 

Another problem with using the chair is that you do not have any back support. Therefore, it may be hard for you to maintain good posture or your back may just get tired. With a normal chair, you have the option of sitting against the back of the chair and adding a lumbar roll or pillow behind your low back to improve the position of your spine. Realistically, most people tend to slump when sitting, and that is true with ball chairs as well.

A feasible option is to use a ball chair for 1-2 hours of your workday. Or you could simply sit on an exercise ball (without the chair) for short periods of time at work. The most important thing about your work station is to have upright posture, which matters more than the chair you use. If you really want to improve core strength, the best way is to do core exercises along with your workouts.

What is a good stretch for my low back?

A lot of my low back patients tell me that they have tried to stretch their backs out by bending forward to touch their toes. Unfortunately, this is not a good stretch for most of them. So how should you stretch out your back if it feels tight or stiff?

Here is a simple exercise that you can do this weekend at home, either on your bed, on the couch or on the floor. Lie on your tummy (face-down), and prop up onto your forearms. Hold this position for a few minutes as you watch AFV, play Angry Birds or read the paper. This is a position that children stay in sometimes when they watch TV or play video games, but it actually is a very healthy position for adults as well! Think about the position that your low back is in throughout most of your day. How often, if ever, do you stretch your spine in the backwards direction? The forward position (flexion) of your spine occurs whenever you sit or bend forward, so it is likely the majority of your day. Therefore it does not need to be stretched in that direction.

So try your new backwards (extension) stretch for at least 3-5 minutes, at least 1-2x/day, and you likely will get better results than other back stretches.



Ref: McKenzie, Robin. Treat Your Own Back, 9th edition. Orthopedic Physical Therapy Product: 2011.

Core strength position Part 3

If you are ready for more challenging core exercises, here are some ideas.

Quadruped (hands and knees): Once you can do arm lifts and leg lifts with good technique and long hold times, you are ready for opposite arm/leg lifts. Get onto your hand and knees. Find your neutral spine position, then draw in your abdominals. Lift one arm and the opposite leg and hold for 5, 10 or up to 30 seconds. There should be no movement in your spine as you hold the arm/leg lift and as you lift and lower the arm/leg. Also, do not lift your arm/legs any higher than your trunk (you do not want your back to extend but to remain neutral). Once you lower the R arm/L leg, then lift the L arm/R leg. Repeat with alternating lifts for a total of 1-2 minutes. To challenge your core, increase your hold times. Then you can do fewer reps.

Plank: This is even more challenging! Lie face-down on the floor, mat or firm bed. Lift your hips upward and push up onto your forearms and toes, to form a plank position. Be sure to find your neutral spine position (you do not want your back arched up or downward). Hold the position until the point of fatigue and then rest down onto the floor/surface. Try to hold for at least 5 seconds. Do not hold any longer than you can maintain the neutral spine position. Work up to longer hold times progressively by practicing for 1-2 minutes/day. Here is an example of how to progress. If you practice consistently, you should be able to hold for >30 seconds within a few weeks.

Day 1: 5 seconds x 5-10 reps
Day 2: 5 seconds x 10-15 reps
Day 3: 10 secons x 6 reps
Day 4: 10 seconds x 10 reps
Day 5: 15 seconds x 4 reps
Day 6: 15 seconds x 7 reps

If you really like core strengthening, I highly recommend Pilates! A DVD or class at the gym can get you started. Once you learn the positions, you can easily transition to doing them by yourself as part of your workouts.

Core strength position Part 2

From yesterday's post we know what the strong core position is, so let's rename it "neutral spine." Now we can talk about some more challenging exercises for your core. Before you begin, make sure you can find your neutral spine position whether you are sitting, standing or squatting. Also be sure to draw in/contract your abdominals without holding your breath. If you cannot do these, look back at "Core strength position" from yesterday.

The two keys of core strengthening as I have instructed so far are the neutral spine position and the abdominal contraction. If you have trouble with either one of those, spend some time practicing until you can do them both properly. The tendency with the abdominal contraction is to hold your breath and to tighten other muscles (such as buttocks, pelvic floor, etc). But work on isolating the deep abdominals, which are so important for your core strength and low back pain prevention. Here are some more core exercises.

Quadruped (hands and knees position): Get onto the floor or bed on your hands and knees. Find your neutral spine position. Draw in your abdominals. Slowly lift up one arm (it does not have to be very high) in front of you. Hold it for 5, 10 or up to 30 seconds. Repeat for the other arm. If it is easy, hold for 30 seconds. Only hold as long as you can maintain the proper back position. Alternate arm lifts for 1-2 minutes. If it is really easy, skip to the next step. Just make sure it is done with perfect technique first.

Next, try lifting one leg by kicking it backwards (do not kick so high that you lose your neutral back position). Hold for 5, 10 or up to 30 seconds. Repeat for the other leg. Alternate leg lifts for 1-2 minutes. If you need more of a challenge, increase your hold times with each kick. Do not forget to focus on your neutral spine position and your deep abdominal contraction. Technique is the most important part of these exercises. Practice for a few minutes per day until you can do them properly with 30 second hold times

To be continued!

BACK HEALTH For A Lifetime

Everyone talks about back pain, but what does it take to have a HEALTHY BACK? One of the main ways is to be active. A sedentary lifestyle decreases your BACK HEALTH and will likely cause back pain in the future.

"The disk appears to live and thrive on movement, and to change and die slowly through lack of it." (1)

There is a disk between each of your vertebrae. You probably have heard of a disk herniation or a slipped disk. Those often result from back trauma (especially bending/twisting your back). But disks can also break down (degenerative disk disease) over the years. So in order to avoid disk problems later in life, it is urgent to keep moving earlier in life. This can be as easy starting a walking program.

Exercise contributes to your back health in many ways:

1. It strengthens your core muscles.

2. It helps you to maintain a healthy weight.

3. It helps to increase circulation (therefore nutrition) to your disks.

4. It can improve your posture (especially upper back exercises).

5. It strengthens your legs so that you can squat more (BODY MECHANICS).

Reference:

(1). Orthopedic Physical Therapy, 3rd ed. Donatelli, RA, Wooden, MJ. Churchill Livingstone, 2001, page 305.

BALANCE for Pain Prevention

Balance exercise helps to strengthen your legs and core, which helps to decrease your risk for joint pain and injuries. So here is one way I add balance exercise to my usual routine.

First, pick a standing activity that takes you at least one-two minutes (for me, it is blow-drying my hair, which takes much longer). Next time you do that activity, do so by standing on one leg. See if you can hold that position for at least 30 seconds before you switch legs. If you do not have good balance, be sure to stand close to a table or counter so you can catch yourself. Be careful not to fall. If you lose your balance, you can always touch your other foot down and then start again.

Once you are good at balancing on one leg and can do so for 30-60 seconds easily, here is the next step. Stand on your left leg and slowly kick your right leg straight out to the side. Kick slowly (about 1-2 seconds up and 1-2 seconds back down). Do not kick very high (about 2 feet). Repeat at least 10x on each side (try to not use arm support if you can do so safely). This exercise is great for improving balance and hip muscle strength!