BACK PAIN
RED FLAG SYMPTOMS IN LOW BACK PAIN
- Age >70 years
- Duration of pain >6 weeks and no improvement with conservative therapy
- Focal neurologic deficit with progressive or disabling symptoms
- History of cancer or high suspicion for cancer
- Immunosupression
- IV drug or alcohol abuse
- Prolonged use of corticosteroids or osteoporosis
- Recent significant trauma or low velocity trauma with age >50 years
- Saddle anesthesia, difficulty urinating or fecal incontinence
- Unexplained fever
- Unexplained weight loss
- Unrelenting night sweats
Forget About Crunches.
Here’s How to Protect Your Back.
By Jane E. Brody : NY Times : June 27, 2011
If you have not suffered a vertebral fracture, adopting an exercise routine that improves posture and strengthens back muscles can go a long way toward preventing one. And if you are already plagued by back pain due to vertebral fractures, the exercises and protective movements described below may bring relief and prevent the problem from getting worse.
These guidelines and exercises have been adapted primarily from recommendations published in the medical journal Osteoporosis International.
First, it is critically important to know what not to do. Avoid those infamous stomach “crunches” and toe touches and any exercise or activity that involves twisting the spine or bending forward from the waist with straight legs.
Next, recall a mantra you may have heard often as a child: Stand up straight. Good posture — proper alignment of body parts when you stand, sit or walk — reduces stress on the spine. Lift your breastbone, and keep your head erect and shoulders back, all the while gently tightening abdominal muscles and maintaining a small hollow in your lower back.
More advice from the experts:
¶ When sitting for long periods, place a rolled towel or small pillow at the small of your back. Walk with your chin in and head upright.
¶ Learn to bend over safely from the hips and knees, not the waist. Start with your feet shoulder-width apart and keep your back straight. Do not twist; turn to face the object you wish to reach before you bend.
¶ To reach your feet (for example, to tie your shoes), sit on a chair and cross one foot at a time over the opposite knee, or stand with one foot on a stool.
¶ Lifting an object can be problematic. If possible, first get down on one knee and lift the object to your waist; then stand up, holding it close to your body.
¶ When carrying packages, use two bags with handles packed as evenly as possible, and carry one bag in each hand. If you have recently had a vertebral fracture, limit the weight you carry to 10 pounds.
Another option: Use a backpack, preferably one with straps that snap in front at the chest and waist. In fact, according to Dr. Kristine Ensrud of the University of Minnesota, one of the recommended back-strengthening exercises involves wearing a small backpacklike device containing a two-kilogram weight.
¶ Avoid overreaching. Don’t reach for objects on a shelf higher than one you can touch with both hands together.
¶ Protect your back when you cough or sneeze. Tighten your abdominal muscles, and place one hand on your back or press your back into a chair or wall for support. Alternatively, gently bend your knees and place one hand on them.
Additionally, exercise that strengthens abdominal muscles will also protect the back. Try this one: Lie on your back with knees bent, feet flat on the floor and a small pillow under your head. Tighten your abdominal muscles by pulling your pelvis and ribs together (push your rib cage toward the floor and tilt your pelvis toward it) while flattening your lower back toward the floor. Hold for five seconds, relax for five seconds, and then repeat 5 to 10 times.
Also helpful is strengthening your core. The Pilates plank exercise, which looks like the “up” part of a push-up, is excellent if you can do it. Lie face down, and raise your body into a benchlike posture, supporting it with your hands and toes and keeping your back flat. Hold the position for a count of 10, or as long as you can without undue strain. Over time, build up to a one-minute plank.
If posture is a problem, a suggested corrective exercise involves sitting or standing as tall as you can with your chin tucked in, stomach tight and chest forward. With your arms extended in a “W” position and shoulders relaxed, bring your elbows back to pinch your shoulder blades together. Hold for a slow count of three and relax for another count of three. Repeat 10 times.
CLINICAL GUIDELINES
Diagnosis and Treatment of Low Back Pain:
A Joint Clinical Practice Guideline from the American College of Physicians and the American Pain Society : October 2007
Recommendation 1:
Clinicians should conduct a focused history and physical examination to help place patients with low back pain into 1 of 3 broad categories: nonspecific low back pain, back pain potentially associated with radiculopathy or spinal stenosis, or back pain potentially associated with another specific spinal cause. The history should include assessment of psychosocial risk factors, which predict risk for chronic disabling back pain (strong recommendation, moderate-quality evidence).
Recommendation 2:
Clinicians should not routinely obtain imaging or other diagnostic tests in patients with nonspecific low back pain (strong recommendation, moderate-quality evidence). See article below which is devoted to the lack of "value" of scans for back pain.
Recommendation 3:
Clinicians should perform diagnostic imaging and testing for patients with low back pain when severe or progressive neurologic deficits are present or when serious underlying conditions are suspected on the basis of history and physical examination (strong recommendation, moderate-quality evidence).
Recommendation 4:
Clinicians should evaluate patients with persistent low back pain and signs or symptoms of radiculopathy or spinal stenosis with magnetic resonance imaging (preferred) or computed tomography only if they are potential candidates for surgery or epidural steroid injection (for suspected radiculopathy) (strong recommendation, moderate-quality evidence).
Recommendation 5:
Clinicians should provide patients with evidence-based information on low back pain with regard to their expected course,advise patients to remain active, and provide information about effective self-care options (strong recommendation, moderate-quality evidence).
Recommendation 6:
For patients with low back pain, clinicians should consider the use of medications with proven benefits in conjunction with back care information and self-care. Clinicians should assess severity of baseline pain and functional deficits, potential benefits, risks, and relative lack of long-term efficacy and safety data before initiating therapy (strong recommendation, moderate-quality evidence). For most patients, first-line medication options are acetaminophen or nonsteroidal anti-inflammatory drugs.
Recommendation 7:
For patients who do not improve with self-care options, clinicians should consider the addition of non pharmacologic therapy with proven benefits—for acute low back pain,spinal manipulation; for chronic or sub acute low back pain,intensive interdisciplinary rehabilitation, exercise therapy,acupuncture, massage therapy, spinal manipulation, yoga, cognitive-behavioral therapy, or progressive relaxation (weak recommendation, moderate-quality evidence).
Scans for Back Pain Ineffective
Tara Parker-Pope : NY Times Article : February 6, 2009
Patients suffering from lower back pain often undergo X-rays or imaging scans to detect the source of the problem. But new research shows scanning to find the source of back pain may do more harm than good.
Researchers from Oregon Health and Science University in Portland reviewed six clinical trials comprised of nearly 2,000 patients with lower back pain. They found that back pain patients who underwent scans didn’t get better any faster or have less pain, depression or anxiety than patients who weren’t scanned. More important, the data suggested that patients who get scanned for back pain may end up with more pain than those who are left alone, according to the report published this week in the medical journal Lancet.
About two thirds of adults suffer from low back pain at some time in their lives, and low back pain is the second most common symptom that sends people to the doctor (upper respiratory problems are first). Studies suggest that more than half the patients who see a doctor for back pain undergo X-rays or another imaging study as a result.
The problem, say researchers, is that back scans can turn up physical changes in the back that aren’t really causing any problem. One well known study from The New England Journal of Medicine put 98 people with no back pain into a magnetic resonance imaging scan. Even though all of them had healthy backs, two out of three of them came back with M.R.I. reports that showed disk problems.
“You can find lots of stuff on X-rays and M.R.I.’s like degenerative disks and arthritis, but these things are very weakly correlated with low back pain,” said study author Dr. Roger Chou, associate professor of medicine at Oregon Health. “We think we’re helping patients by doing a test, but we’re adding cost, exposing people to radiation and people may be getting unnecessary surgery. They start to think of themselves as having a horrible back problem and they stop doing exercise and things that are good for them, when in reality, a lot of people have degenerative disks and arthritis and have no pain at all.”
Dr. Chou said patients should ask their doctors why a scan or X-ray is needed rather than using pain relief and exercise to cope while a back heals on its own. Most back pain gets better within 30 days if a patient takes normal precautions after a pain episode. If back pain persists for longer than a month, or if symptoms suggest a more serious problem like an infection or tumor, then an X-ray or scan may be needed, Dr. Chou said.
“I think patients should question whether they really need it,” Dr. Chou said. “From a societal perspective, it’s important because we’re wasting a lot of money that could be used for better purposes. But from an individual patient’s perspective, doing X-rays and M.R.I.’s can lead you down a path that you don’t want to go down.”
To learn more about back pain, read my Well blog post from last year, “Back Pain Spending Surge Shows No Benefit.” In 2004, Times reporter Gina Kolata wrote, “Healing a Bad Back is Often an Effort in Painful Futility.” Read the New Yorker article from 2002 called “A Knife in the Back,” by Dr. Jerome Groopman, about the risks of back surgery. And look at art created by back pain sufferers and other artists with chronic pain in “Pain as an Art Form.”
Back Pain : Overview
Definition:
Pain felt in your lower back may come from the spine, muscles, nerves, or other structures in that region. It may also radiate from other areas like your mid or upper back, a hernia in the groin, or a problem in the testicles or ovaries.
You may feel a variety of symptoms if you've hurt your back. You may have a tingling or burning sensation, a dull aching, or sharp pain. You also may experience weakness in your legs or feet.
It won't necessarily be one event that actually causes your pain. You may have been doing many things improperly -- like standing, sitting, or lifting -- for a long time. Then suddenly, one simple movement, like reaching for something in the shower or bending from your waist, leads to the feeling of pain.
Alternative Names:
Backache; Low back pain; Lumbar pain; Pain - back
Considerations:
If you are like most people, you will have at least one backache in your life. While such pain or discomfort can happen anywhere in your back, the most common area affected is your low back. This is because the low back supports most of your body's weight.
Low back pain is the #2 reason that Americans see their doctor -- second only to colds and flus. Many back-related injuries happen at work. But you can change that. There are many things you can do to lower your chances of getting back pain.
Most back problems will get better on their own. The key is to know when you need to seek medical help and when self-care measures alone will allow you to get better.
Low back pain may be acute (short-term), lasting less than one month, or chronic (long-term, continuous, ongoing), lasting longer than three months. While getting acute back pain more than once is common, continuous long-term pain is not.
Common Causes:
You'll usually first feel back pain just after you lift a heavy object, move suddenly, sit in one position for a long time, or have an injury or accident. But prior to that moment in time, the structures in your back may be losing strength or integrity.
The specific structure in your back responsible for your pain is hardly ever identified. Whether identified or not, there are several possible sources of low back pain:
You are at particular risk for low back pain if you:
Many people will feel better within one week after the start of back pain. After another 4-6 weeks, the back pain will likely be completely gone. To get better quickly, take the right steps when you first get pain.
A common misconception about back pain is that you need to rest and avoid activity for a long time. In fact, bed rest is NOT recommended.
If you have no indication of a serious underlying cause for your back pain (like loss of bowel or bladder control, weakness, weight loss, or fever), then you should reduce physical activity only for the first couple of days. Gradually resume your usual activities after that. Here are some tips for how to handle pain early on:
Do not perform activities that involve heavy lifting or twisting of your back for the first 6 weeks after the pain begins. After 2-3 weeks, you should gradually resume exercise.
Begin with light cardiovascular training. Walking, riding a stationary bicycle, and swimming are great examples. Such aerobic activities can help blood flow to your back and promote healing. They also strengthen muscles in your stomach and back.
Stretching and strengthening exercises are important in the long run. However, starting these exercises too soon after an injury can make your pain worse. A physical therapist can help you determine when to begin stretching and strengthening exercises and how to do so.
AVOID the following exercises during initial recovery unless your doctor or physical therapist says it is okay:
Call 911 if you have lost bowel or bladder control. Otherwise, call your doctor if you have:
What to Expect at Your Health Care Provider's Office:
When you first see your doctor, you will be asked questions about your back pain, including how often it occurs and how severe it is. Your doctor will try to determine the cause of your back pain and whether it is likely to quickly get better with simple measures such as ice, mild painkillers, physical therapy, and proper exercises. Most of the time, back pain will get better using these approaches.
Questions will include:
To test nerve function, the doctor will use a rubber hammer to check your reflexes. Touching your legs in many locations with a pin, cotton swab, or feather tests your sensory nervous system (how well you feel). Your doctor will instruct you to speak up if there are areas where the sensation from the pin, cotton, or feather is duller.
Most people with back pain recover within four to six weeks. Therefore, your doctor will probably not order any tests during the first visit. However, if you have any of the symptoms or circumstances below, your doctor may order imaging tests even at this initial exam:
Tests that might be ordered include:
an X-ray, a myelogram (an X-ray or CT scan of the spine after dye has been injected into the spinal column), a CT of the lower spine or MRI of the lower spine.
Hospitalization, traction, or spinal surgery should only be considered if nerve damage is present or the condition fails to heal after a prolonged period.
Many people benefit from physical therapy. Your doctor will determine if you need to see a physical therapist and can refer you to one in your area. The physical therapist will begin by using methods to reduce your pain. Then, the therapist will teach you ways to prevent getting back pain again.
If your pain lasts longer than one month, your primary care doctor may send you to see either an orthopedist (bone specialist) or neurologist (nerve specialist).
Prevention:
Exercise is important for preventing future back pain. Through exercise you can:
To prevent back pain, it is also very important to learn to lift and bend properly. Follow these tips:
Back Pain Eludes Perfect Solutions
By Leslie Berger : NY Times Article : May 13, 2008
Back pain is one of the most common physical complaints, so it’s no surprise that treatments for it have multiplied over the years. That ought to be good; instead, many patients find that sudden back pain opens the door to a world of medical confusion.
The effectiveness of virtually every pharmaceutical or surgical remedy, however, has been questioned. And for all the money sufferers spend on doctor visits, hospital stays, procedures and drugs, backs are not improving. The Journal of the American Medical Association reported that spending on back treatments jumped 65 percent to nearly $86 billion from 1997 to 2005, after adjusting for inflation. But during the same period, the proportion of people with reduced function because of spine problems increased, even after controlling for an aging population.
“Low back pain represents so many different diseases that there really hasn’t been a breakthrough treatment,” said Dr. Russell K. Portenoy, chairman of the department of pain medicine and palliative care at Beth Israel Medical Center in New York. “It’s good for the public to know how little we know.”
The mystery begins with the first doctor’s visit. The exact cause of back pain is never found in 85 percent of patients, said Dr. Dennis C. Turk, professor of anesthesiology and pain research at the University of Washington and a past president of the American Pain Society. Even magnetic resonance imaging seldom sheds light; in many studies the scans have picked up spinal abnormalities in many people who have never reported back pain.
So what’s a sufferer to do?
Narcotic pain relievers like OxyContin, used regularly by more than eight million Americans, can help, but doctors remain deeply divided over when to prescribe them. The painkillers can also be highly addictive and lead to mood changes.
“I think we are an overmedicated society, and I would not recommend narcotics for everyday back pain except for in most rare of circumstances,” said Dr. James N. Weinstein, editor of the medical journal Spine and chairman of the department of orthopedic surgery at Dartmouth-Hitchcock Medical Center in Lebanon, N.H.
Alternatives to narcotics have proved problematic, too. Two anti-inflammatory drugs, Vioxx and Bextra, were taken off the market after being linked to heart attacks. And ibuprofen and aspirin can cause gastrointestinal bleeding or organ damage at high doses.
Spinal injections of steroids and anesthetics increased by nearly a third during the 1990s, but several scientific reviews found scant evidence that these provided more than short-term relief. Some doctors have begun prescribing drugs like Lyrica, an anticonvulsant, and Cymbalta, an antidepressant, to treat chronic back pain. But the data on antidepressants is also mixed. A study last fall in The Annals of Internal Medicine found that antidepressants help back sufferers, but this year a review by the respected Cochrane Collaboration, a nonprofit organization for health information, concluded there was no evidence that antidepressants offered relief.
While the quest for a safe and effective pain pill continues, Americans undergo more than 300,000 spinal fusion surgeries a year, at an average cost of $59,000 each, according to the National Center for Health Statistics. Almost as many undergo laminectomies or diskectomies to remove damaged vertebrae and disks.
For some, back surgery can be life-changing, eliminating pain and disability. But for others, it can have serious consequences. One study found that 11.6 percent of patients in the 78 spinal surgeries that were analyzed developed infections and other complications.
Newer procedures, like implants of medication pumps and stimulators, have received mixed reviews, too. The jury is still out on kyphoplasty, an outpatient procedure for patients with vertebrae fracture from osteoporosis. The doctor inserts a needle into the spine and inflates a balloon, then injects a cement, gluing the bones together. The procedure works only for some patients.
With such uncertainties, it is little wonder that many doctors have fallen back on more traditional approaches to easing the pain, like exercise or counseling. This year, the Accreditation Council for Graduate Medical Education began requiring that medical residents who want to become pain specialists study not only anesthesiology but also psychology, neurology and rehabilitative medicine.
The reality is that most people with back pain heal on their own, slowly, without major intervention. “The best treatment for straightforward back pain without a specific diagnosis is reactivating yourself to what you normally do as fast as possible,” Dr. Weinstein, the Spine editor, said.
Twist and Ouch
By Gretchen Reynolds : NY Times Article : October 28, 2007
Not long after a typically underwhelming showing by the British contingent at the Wimbledon championships in July, the British Journal of Sports Medicine published the results of a study that suggested to beleaguered English tennis fans that things are only going to get worse. In the study, researchers from the Royal National Orthopaedic Hospital scanned the spines of 33 elite adolescent tennis players, male and female, who trained at the National Tennis Centre, the club of choice for Britain’s most promising young prospects. None of the players had reported back pain. But their backs, it turned out, were a mess.
Twenty-eight of the teenagers — 85 percent — were found to have serious spinal abnormalities, ranging from cysts to fractures. Twenty-three had early-stage joint disease and 13 had herniated discs or desiccated, shriveled discs, common in septuagenarians but much less prevalent in teenagers. These kids, the cream of the next generation of British tennis, had backs 60 years older than they were.
“Tennis requires more frequent, repetitive and rapid rotation from the lumbar spine than other sports,” the authors wrote. Playing it is particularly detrimental “during the growth spurt.” High-level tennis, in other words, can be brutal on the young.
But as many of us know from debilitating firsthand experience, back problems don’t afflict just teenage tennis players. According to various studies, at least a third of all competitive football players will hurt their lower backs during play, as will a third of gymnasts and 25 percent of serious rowers. About 40 percent of divers will develop a spinal stress fracture, and many cyclists will experience constant, grinding back pain while riding. In one study, six out of seven rhythmic gymnasts — those madly grinning ribbon twirlers — reported severe lower back problems. The harshest sport, however, seems to be golf. Ninety percent of injuries to professional golfers involve the lower back and the neck, and almost 80 percent of professionals will miss at least one tournament because of back pain.
If you’re a runner, do a backbend of thanksgiving: runners statistically have a lower risk than most athletes of developing back problems. But for everyone else, the news is . . . painful. So what, if anything, can you do to preserve and protect your spine?
To build a better back, most experts agree, you need a solid core. “The core” is one of those areas of the body that coaches and athletes refer to constantly but few people can accurately locate. “It’s not just the abdominal area, as many people think,” says Vijay Vad, a sports medicine specialist at the Hospital for Special Surgery in New York City and a back-care adviser to the PGA Tour and the professional men’s tennis circuit. “To really include all of the elements that move and stabilize the spine, you have to go from your knees to your nipples. That’s the core.”
The muscles, ligaments and tendons that make up the elaborate core muscle system provide rigging for the spine. The rectus, transverse and oblique abdominals, for instance — the big muscles at the front and sides of the spine — are particularly important in stabilizing the back. So are the less familiar intertransversi, interspinalis and multifidus muscles, which link to the larger abdominal group but which rarely figure in magazine articles about washboard abs. Each of these muscles must be strong and supple if the spine is to remain stable.
Endurance is important, too. It’s perhaps the most crucial element of core health, since it keeps the stabilizing muscles and connective tissues going through a long workout or game. “You have to have enough muscular endurance to be able to maintain spinal stability throughout the entire length of an activity,” says Michael Higgins, the director of athletic-training education at Towson University in Maryland and the author of several prominent academic articles about back injuries in athletes. “Without endurance, what you often see is that near the end of a game, the muscles can’t quite control the movement of the spine adequately anymore.” Whether you’re playing four quarters of football, three sets of tennis, 18 holes of golf or riding 100 miles on a bike, if your core can’t keep up, your back is sure to let you know about it.
Many lower back problems are caused by the very athleticism that modern sports demand. “The forces involved in sports nowadays are enormous,” Higgins says. “What you see in some of these sports are very powerful athletes creating high levels of extension and compression of the spine.”
Consider the forces applied to the lower back during certain activities: The torque created by a proper golf swing can produce almost 1,700 pounds of pressure on the lower spine. Rowers can put about 1,300 pounds of pressure on their backs at the catch of their stroke. And the “peak compressive load,” as the scientific parlance goes, created by a football lineman slamming into his opponent can be close to 2,000 pounds.
Often, the muscles that produce such power are accompanied by a relative weakness and inflexibility — ever see a lineman touch his toes? — in muscle groups not being used. Sprinters, for instance, tend to have mountainous quadriceps but weaker, tighter hamstrings. The hamstrings, which, like the quads, are tied into the lumbar spine system, can’t balance the force being produced by stronger muscles. As a result, the spine loses stability.
Something similar occurs in golfers, especially the good ones. “If you’re a bad golfer, like me, and you use your shoulders to power the swing, instead of your back, you probably won’t hurt yourself,” says Christopher Bono, an assistant professor of orthopedic surgery at Harvard Medical School and the chief of spine services at Brigham and Women’s Hospital in Boston. “If, though, you’ve got a good swing, you’re probably going to hurt your back.”
Just ask Arron Oberholser, the PGA Tour golfer who has ranked as high as 22nd in the world but who has also, at the advanced age of 32, endured multiple ruptured discs in his lower spine.
“I thought a couple of times that my career might be over,” he says. “There seems to be something about the repetitive golf swing that primes you for this injury.”
Power and consistency, in other words, can be your back’s undoing. “Strength, by itself, is not the answer,” Higgins says. As the authors of the British study pointed out, those young tennis players were strong. But they were strong only in terms of their tennis muscles, particularly those in the shoulders. Compared with their counterparts in other national junior programs, British players rarely visit the weight room. They typically don’t stretch or cross-train. Instead they hit and hit and hit, repetitively, propulsively, their strokes becoming faster and sharper, even as their backs insidiously break down.
Having a strong back, you will be happy to hear, means not doing sit-ups. Ever. “Sit-ups are not healthy for the back,” Higgins says. “They can severely compress the lumbar spine.”
Abdominal crunches, on the other hand, in which you raise your head and trunk slightly from the ground without pulling yourself upright, improve back health significantly. “Crunches build core endurance and strength without stressing the spine,” Higgins says.
A complete back-health exercise regimen must include more than crunches, of course (see sidebar, right). “You need to activate and strengthen all of the muscles that circle the spine like a belt,” Higgins says. You can do this by slightly contracting your abdominal muscles during workouts. Don’t suck in your gut; that narrows the band of support around the spine. “You only need to contract the abdominal muscles by about
10 percent to get the spinal benefits of the abdominal bracing,” Higgins says.
Don’t forget flexibility, either. In 2004, Vad and other researchers led a study of 42 professional golfers and found that those with the smallest range of motion in their lead hip and lower back had the highest frequency of back pain. “If you have a loss of flexibility in the hips, the back will take up the slack and absorb more of the pressures of the swing than it should,” Vad says. “Yoga, Pilates, dance — they’re all good for core flexibility.”
If your back aches for more than a few weeks, or if the pain is acute or radiating, visit a doctor. “Most back injuries will clear up on their own within six to eight weeks, if you rest adequately,” Vad says. “Surgery is very rarely necessary, maybe in 3 to 5 percent of cases.”
Finally, don’t despair if your back hurts. For many athletes, pain has been a necessary prelude to wisdom. “Before my back injuries, I really thought this golf thing was so easy,” Oberholser says, almost wistfully. “I thought, ‘I can do this into my 50s, no problem.’ ” Now, after reinjuring his back yet again last spring, he’s in the midst of an elaborate overhaul of his swing mechanics, his strength training, his posture — in short, his entire game. “I’m being a lot more careful than I used to be,” he says. “I’m doing the exercises, following the advice. I’m really optimistic about next season, but cautious, too. I’ve learned that you have to take care of your back, because, otherwise, boy, it’ll take you down with you if it goes out.”
SUPPORT THAT LAZY SPINE:
The best exercises for strengthening your back
Entire books have been devoted to workout routines for the back. But you can save yourself some trouble by focusing on these three exercises, which work most of the large muscles in the body’s core. Do them four times a week, breathing slowly and steadily throughout.
CURL UP
Lie on your back with your knees bent. Slide your hands under your lower back to provide support; you don’t want your spine flat against the floor. Straighten one leg. Then, while keeping your neck and lower spine straight and unmoving, lift your shoulders and chest off the floor. Hold the position for about eight seconds. Repeat 10 times, then switch legs and do another 10.
SIDE BRIDGE
Lie on your side, with your legs bent at the knee and your upper hand across your chest. Bend your lower arm so that your elbow is pointing away from your chest. Slowly raise your shoulders, keeping your spine straight, and hold for 8 to 10 seconds. Repeat on the other side. After a few weeks, do the exercise with your legs straight.
BIRD DOG
Start on all fours, then slowly lift your right arm and left leg until each is parallel to the ground. Hold for eight seconds. Repeat with the opposite arm and leg. Do 10 reps on each side. Keep your spine straight, hips level and abdominal muscles slightly contracted. And don’t forget to breathe.
Here’s How to Protect Your Back.
By Jane E. Brody : NY Times : June 27, 2011
If you have not suffered a vertebral fracture, adopting an exercise routine that improves posture and strengthens back muscles can go a long way toward preventing one. And if you are already plagued by back pain due to vertebral fractures, the exercises and protective movements described below may bring relief and prevent the problem from getting worse.
These guidelines and exercises have been adapted primarily from recommendations published in the medical journal Osteoporosis International.
First, it is critically important to know what not to do. Avoid those infamous stomach “crunches” and toe touches and any exercise or activity that involves twisting the spine or bending forward from the waist with straight legs.
Next, recall a mantra you may have heard often as a child: Stand up straight. Good posture — proper alignment of body parts when you stand, sit or walk — reduces stress on the spine. Lift your breastbone, and keep your head erect and shoulders back, all the while gently tightening abdominal muscles and maintaining a small hollow in your lower back.
More advice from the experts:
¶ When sitting for long periods, place a rolled towel or small pillow at the small of your back. Walk with your chin in and head upright.
¶ Learn to bend over safely from the hips and knees, not the waist. Start with your feet shoulder-width apart and keep your back straight. Do not twist; turn to face the object you wish to reach before you bend.
¶ To reach your feet (for example, to tie your shoes), sit on a chair and cross one foot at a time over the opposite knee, or stand with one foot on a stool.
¶ Lifting an object can be problematic. If possible, first get down on one knee and lift the object to your waist; then stand up, holding it close to your body.
¶ When carrying packages, use two bags with handles packed as evenly as possible, and carry one bag in each hand. If you have recently had a vertebral fracture, limit the weight you carry to 10 pounds.
Another option: Use a backpack, preferably one with straps that snap in front at the chest and waist. In fact, according to Dr. Kristine Ensrud of the University of Minnesota, one of the recommended back-strengthening exercises involves wearing a small backpacklike device containing a two-kilogram weight.
¶ Avoid overreaching. Don’t reach for objects on a shelf higher than one you can touch with both hands together.
¶ Protect your back when you cough or sneeze. Tighten your abdominal muscles, and place one hand on your back or press your back into a chair or wall for support. Alternatively, gently bend your knees and place one hand on them.
Additionally, exercise that strengthens abdominal muscles will also protect the back. Try this one: Lie on your back with knees bent, feet flat on the floor and a small pillow under your head. Tighten your abdominal muscles by pulling your pelvis and ribs together (push your rib cage toward the floor and tilt your pelvis toward it) while flattening your lower back toward the floor. Hold for five seconds, relax for five seconds, and then repeat 5 to 10 times.
Also helpful is strengthening your core. The Pilates plank exercise, which looks like the “up” part of a push-up, is excellent if you can do it. Lie face down, and raise your body into a benchlike posture, supporting it with your hands and toes and keeping your back flat. Hold the position for a count of 10, or as long as you can without undue strain. Over time, build up to a one-minute plank.
If posture is a problem, a suggested corrective exercise involves sitting or standing as tall as you can with your chin tucked in, stomach tight and chest forward. With your arms extended in a “W” position and shoulders relaxed, bring your elbows back to pinch your shoulder blades together. Hold for a slow count of three and relax for another count of three. Repeat 10 times.
CLINICAL GUIDELINES
Diagnosis and Treatment of Low Back Pain:
A Joint Clinical Practice Guideline from the American College of Physicians and the American Pain Society : October 2007
Recommendation 1:
Clinicians should conduct a focused history and physical examination to help place patients with low back pain into 1 of 3 broad categories: nonspecific low back pain, back pain potentially associated with radiculopathy or spinal stenosis, or back pain potentially associated with another specific spinal cause. The history should include assessment of psychosocial risk factors, which predict risk for chronic disabling back pain (strong recommendation, moderate-quality evidence).
Recommendation 2:
Clinicians should not routinely obtain imaging or other diagnostic tests in patients with nonspecific low back pain (strong recommendation, moderate-quality evidence). See article below which is devoted to the lack of "value" of scans for back pain.
Recommendation 3:
Clinicians should perform diagnostic imaging and testing for patients with low back pain when severe or progressive neurologic deficits are present or when serious underlying conditions are suspected on the basis of history and physical examination (strong recommendation, moderate-quality evidence).
Recommendation 4:
Clinicians should evaluate patients with persistent low back pain and signs or symptoms of radiculopathy or spinal stenosis with magnetic resonance imaging (preferred) or computed tomography only if they are potential candidates for surgery or epidural steroid injection (for suspected radiculopathy) (strong recommendation, moderate-quality evidence).
Recommendation 5:
Clinicians should provide patients with evidence-based information on low back pain with regard to their expected course,advise patients to remain active, and provide information about effective self-care options (strong recommendation, moderate-quality evidence).
Recommendation 6:
For patients with low back pain, clinicians should consider the use of medications with proven benefits in conjunction with back care information and self-care. Clinicians should assess severity of baseline pain and functional deficits, potential benefits, risks, and relative lack of long-term efficacy and safety data before initiating therapy (strong recommendation, moderate-quality evidence). For most patients, first-line medication options are acetaminophen or nonsteroidal anti-inflammatory drugs.
Recommendation 7:
For patients who do not improve with self-care options, clinicians should consider the addition of non pharmacologic therapy with proven benefits—for acute low back pain,spinal manipulation; for chronic or sub acute low back pain,intensive interdisciplinary rehabilitation, exercise therapy,acupuncture, massage therapy, spinal manipulation, yoga, cognitive-behavioral therapy, or progressive relaxation (weak recommendation, moderate-quality evidence).
Scans for Back Pain Ineffective
Tara Parker-Pope : NY Times Article : February 6, 2009
Patients suffering from lower back pain often undergo X-rays or imaging scans to detect the source of the problem. But new research shows scanning to find the source of back pain may do more harm than good.
Researchers from Oregon Health and Science University in Portland reviewed six clinical trials comprised of nearly 2,000 patients with lower back pain. They found that back pain patients who underwent scans didn’t get better any faster or have less pain, depression or anxiety than patients who weren’t scanned. More important, the data suggested that patients who get scanned for back pain may end up with more pain than those who are left alone, according to the report published this week in the medical journal Lancet.
About two thirds of adults suffer from low back pain at some time in their lives, and low back pain is the second most common symptom that sends people to the doctor (upper respiratory problems are first). Studies suggest that more than half the patients who see a doctor for back pain undergo X-rays or another imaging study as a result.
The problem, say researchers, is that back scans can turn up physical changes in the back that aren’t really causing any problem. One well known study from The New England Journal of Medicine put 98 people with no back pain into a magnetic resonance imaging scan. Even though all of them had healthy backs, two out of three of them came back with M.R.I. reports that showed disk problems.
“You can find lots of stuff on X-rays and M.R.I.’s like degenerative disks and arthritis, but these things are very weakly correlated with low back pain,” said study author Dr. Roger Chou, associate professor of medicine at Oregon Health. “We think we’re helping patients by doing a test, but we’re adding cost, exposing people to radiation and people may be getting unnecessary surgery. They start to think of themselves as having a horrible back problem and they stop doing exercise and things that are good for them, when in reality, a lot of people have degenerative disks and arthritis and have no pain at all.”
Dr. Chou said patients should ask their doctors why a scan or X-ray is needed rather than using pain relief and exercise to cope while a back heals on its own. Most back pain gets better within 30 days if a patient takes normal precautions after a pain episode. If back pain persists for longer than a month, or if symptoms suggest a more serious problem like an infection or tumor, then an X-ray or scan may be needed, Dr. Chou said.
“I think patients should question whether they really need it,” Dr. Chou said. “From a societal perspective, it’s important because we’re wasting a lot of money that could be used for better purposes. But from an individual patient’s perspective, doing X-rays and M.R.I.’s can lead you down a path that you don’t want to go down.”
To learn more about back pain, read my Well blog post from last year, “Back Pain Spending Surge Shows No Benefit.” In 2004, Times reporter Gina Kolata wrote, “Healing a Bad Back is Often an Effort in Painful Futility.” Read the New Yorker article from 2002 called “A Knife in the Back,” by Dr. Jerome Groopman, about the risks of back surgery. And look at art created by back pain sufferers and other artists with chronic pain in “Pain as an Art Form.”
Back Pain : Overview
Definition:
Pain felt in your lower back may come from the spine, muscles, nerves, or other structures in that region. It may also radiate from other areas like your mid or upper back, a hernia in the groin, or a problem in the testicles or ovaries.
You may feel a variety of symptoms if you've hurt your back. You may have a tingling or burning sensation, a dull aching, or sharp pain. You also may experience weakness in your legs or feet.
It won't necessarily be one event that actually causes your pain. You may have been doing many things improperly -- like standing, sitting, or lifting -- for a long time. Then suddenly, one simple movement, like reaching for something in the shower or bending from your waist, leads to the feeling of pain.
Alternative Names:
Backache; Low back pain; Lumbar pain; Pain - back
Considerations:
If you are like most people, you will have at least one backache in your life. While such pain or discomfort can happen anywhere in your back, the most common area affected is your low back. This is because the low back supports most of your body's weight.
Low back pain is the #2 reason that Americans see their doctor -- second only to colds and flus. Many back-related injuries happen at work. But you can change that. There are many things you can do to lower your chances of getting back pain.
Most back problems will get better on their own. The key is to know when you need to seek medical help and when self-care measures alone will allow you to get better.
Low back pain may be acute (short-term), lasting less than one month, or chronic (long-term, continuous, ongoing), lasting longer than three months. While getting acute back pain more than once is common, continuous long-term pain is not.
Common Causes:
You'll usually first feel back pain just after you lift a heavy object, move suddenly, sit in one position for a long time, or have an injury or accident. But prior to that moment in time, the structures in your back may be losing strength or integrity.
The specific structure in your back responsible for your pain is hardly ever identified. Whether identified or not, there are several possible sources of low back pain:
- Small fractures to the spine from osteoporosis
- Muscle spasm (very tense muscles that remain contracted)
- Ruptured or herniated disk
- Degeneration of the disks
- Poor alignment of the vertebrae
- Spinal stenosis (narrowing of the spinal canal)
- Strain or tears to the muscles or ligaments supporting the back
- Spine curvatures (like scoliosis or kyphosis) which may be inherited and seen in children or teens
- Other medical conditions like fibromyalgia
You are at particular risk for low back pain if you:
- Work in construction or another job requiring heavy lifting, lots of bending and twisting, or whole body vibration (like truck driving or using a sandblaster)
- Have bad posture
- Are pregnant
- Are over age 30
- Smoke, don't exercise, or are overweight
- Have arthritis or osteoporosis
- Have a low pain threshold
- Feel stressed or depressed
- Bladder infection
- Kidney stone
- Endometriosis
- Ovarian cancer
- Ovarian cysts
- Testicular torsion (twisted testicle)
Many people will feel better within one week after the start of back pain. After another 4-6 weeks, the back pain will likely be completely gone. To get better quickly, take the right steps when you first get pain.
A common misconception about back pain is that you need to rest and avoid activity for a long time. In fact, bed rest is NOT recommended.
If you have no indication of a serious underlying cause for your back pain (like loss of bowel or bladder control, weakness, weight loss, or fever), then you should reduce physical activity only for the first couple of days. Gradually resume your usual activities after that. Here are some tips for how to handle pain early on:
- Stop normal physical activity for the first few days. This helps calm your symptoms and reduce inflammation.
- Apply heat or ice to the painful area. Try ice for the first 48-72 hours, then use heat after that.
- Take over-the-counter pain relievers such as ibuprofen (Advil, Motrin IB) or acetaminophen (Tylenol).
Do not perform activities that involve heavy lifting or twisting of your back for the first 6 weeks after the pain begins. After 2-3 weeks, you should gradually resume exercise.
Begin with light cardiovascular training. Walking, riding a stationary bicycle, and swimming are great examples. Such aerobic activities can help blood flow to your back and promote healing. They also strengthen muscles in your stomach and back.
Stretching and strengthening exercises are important in the long run. However, starting these exercises too soon after an injury can make your pain worse. A physical therapist can help you determine when to begin stretching and strengthening exercises and how to do so.
AVOID the following exercises during initial recovery unless your doctor or physical therapist says it is okay:
- Jogging
- Football
- Golf
- Ballet
- Weight lifting
- Leg lifts when lying on your stomach
- Sit-ups with straight legs (rather than bent knees)
Call 911 if you have lost bowel or bladder control. Otherwise, call your doctor if you have:
- Unexplained fever with back pain.
- Back pain after a severe blow or fall.
- Redness or swelling on the back or spine.
- Pain traveling down your legs below the knee.
- Weakness or numbness in your buttocks, thigh, leg, or pelvis.
- Burning with urination or blood in your urine.
- Worse pain when you lie down or pain that awakens you at night.
- Very sharp pain.
- You have been losing weight unintentionally
- You use steroids or intravenous drugs.
- You have never had or been evaluated for back pain before.
- You have had back pain before but this episode is distinctly different.
- This episode of back pain has lasted longer than four weeks.
What to Expect at Your Health Care Provider's Office:
When you first see your doctor, you will be asked questions about your back pain, including how often it occurs and how severe it is. Your doctor will try to determine the cause of your back pain and whether it is likely to quickly get better with simple measures such as ice, mild painkillers, physical therapy, and proper exercises. Most of the time, back pain will get better using these approaches.
Questions will include:
- Is your pain on one side only or both sides?
- What does the pain feel like? Is it dull, sharp, throbbing, or burning?
- Is this the first time you have had back pain?
- When did the pain begin? Did it start suddenly?
- Did you have a particular injury or accident?
- What were you doing just before the pain began? Were you lifting or bending? Sitting at your computer? Driving a long distance?
- If you have had back pain before, is this pain similar or different? In what way is it different?
- Do you know the cause of previous episodes of back pain?
- How long does each episode of back pain usually last?
- Do you feel the pain anywhere other than your back, like your hip, thigh, leg or feet?
- Do you have any numbness or tingling? Any weakness or loss of function in your leg or elsewhere?
- What makes the pain worse? Lifting, twisting, standing, or sitting for long periods of time?
- What makes you feel better?
- Are there any other symptoms present? Weight loss? Fever? Change in urination? Change in bowel habits?
- Sit, stand, and walk. While walking, your doctor may ask you to try walking on your toes and then your heels.
- Bend forward, backward, and sideways.
- Lift your legs straight up while lying down. If the pain is worse when you do this, you may have sciatica, especially if you also feel numbness or tingling in one of your legs.
To test nerve function, the doctor will use a rubber hammer to check your reflexes. Touching your legs in many locations with a pin, cotton swab, or feather tests your sensory nervous system (how well you feel). Your doctor will instruct you to speak up if there are areas where the sensation from the pin, cotton, or feather is duller.
Most people with back pain recover within four to six weeks. Therefore, your doctor will probably not order any tests during the first visit. However, if you have any of the symptoms or circumstances below, your doctor may order imaging tests even at this initial exam:
- Pain that has lasted longer than one month
- Numbness
- Muscle weakness
- Accident or injury
- Fever
- If you are over 65
- You have had cancer or have a strong family history of cancer
- Weight loss
Tests that might be ordered include:
an X-ray, a myelogram (an X-ray or CT scan of the spine after dye has been injected into the spinal column), a CT of the lower spine or MRI of the lower spine.
Hospitalization, traction, or spinal surgery should only be considered if nerve damage is present or the condition fails to heal after a prolonged period.
Many people benefit from physical therapy. Your doctor will determine if you need to see a physical therapist and can refer you to one in your area. The physical therapist will begin by using methods to reduce your pain. Then, the therapist will teach you ways to prevent getting back pain again.
If your pain lasts longer than one month, your primary care doctor may send you to see either an orthopedist (bone specialist) or neurologist (nerve specialist).
Prevention:
Exercise is important for preventing future back pain. Through exercise you can:
- Improve your posture
- Strengthen your back and improve flexibility
- Lose weight
- Avoid falls
To prevent back pain, it is also very important to learn to lift and bend properly. Follow these tips:
- If an object is too heavy or awkward, get help.
- Spread your feet apart to give a wide base of support.
- Stand as close to the object you are lifting as possible.
- Bend at your knees, not at your waist.
- Tighten your stomach muscles as you lift the object up or lower it down.
- Hold the object as close to your body as you can.
- Lift using your leg muscles.
- As you stand up with the object, DO NOT bend forward.
- DO NOT twist while you are bending for the object, lifting it up, or carrying it.
- Avoid standing for long periods of time. If you must for your work, try using a stool. Alternate resting each foot on it.
- DO NOT wear high heels. Use cushioned soles when walking.
- When sitting for work, especially if using a computer, make sure that your chair has a straight back with adjustable seat and back, armrests, and a swivel seat.
- Use a stool under your feet while sitting so that your knees are higher than your hips.
- Place a small pillow or rolled towel behind your lower back while sitting or driving for long periods of time.
- If you drive long distance, stop and walk around every hour. Bring your seat as far forward as possible to avoid bending. Don't lift heavy objects just after a ride.
- Quit smoking.
- Lose weight.
- Learn to relax. Try methods like yoga, tai chi, or massage.
Back Pain Eludes Perfect Solutions
By Leslie Berger : NY Times Article : May 13, 2008
Back pain is one of the most common physical complaints, so it’s no surprise that treatments for it have multiplied over the years. That ought to be good; instead, many patients find that sudden back pain opens the door to a world of medical confusion.
The effectiveness of virtually every pharmaceutical or surgical remedy, however, has been questioned. And for all the money sufferers spend on doctor visits, hospital stays, procedures and drugs, backs are not improving. The Journal of the American Medical Association reported that spending on back treatments jumped 65 percent to nearly $86 billion from 1997 to 2005, after adjusting for inflation. But during the same period, the proportion of people with reduced function because of spine problems increased, even after controlling for an aging population.
“Low back pain represents so many different diseases that there really hasn’t been a breakthrough treatment,” said Dr. Russell K. Portenoy, chairman of the department of pain medicine and palliative care at Beth Israel Medical Center in New York. “It’s good for the public to know how little we know.”
The mystery begins with the first doctor’s visit. The exact cause of back pain is never found in 85 percent of patients, said Dr. Dennis C. Turk, professor of anesthesiology and pain research at the University of Washington and a past president of the American Pain Society. Even magnetic resonance imaging seldom sheds light; in many studies the scans have picked up spinal abnormalities in many people who have never reported back pain.
So what’s a sufferer to do?
Narcotic pain relievers like OxyContin, used regularly by more than eight million Americans, can help, but doctors remain deeply divided over when to prescribe them. The painkillers can also be highly addictive and lead to mood changes.
“I think we are an overmedicated society, and I would not recommend narcotics for everyday back pain except for in most rare of circumstances,” said Dr. James N. Weinstein, editor of the medical journal Spine and chairman of the department of orthopedic surgery at Dartmouth-Hitchcock Medical Center in Lebanon, N.H.
Alternatives to narcotics have proved problematic, too. Two anti-inflammatory drugs, Vioxx and Bextra, were taken off the market after being linked to heart attacks. And ibuprofen and aspirin can cause gastrointestinal bleeding or organ damage at high doses.
Spinal injections of steroids and anesthetics increased by nearly a third during the 1990s, but several scientific reviews found scant evidence that these provided more than short-term relief. Some doctors have begun prescribing drugs like Lyrica, an anticonvulsant, and Cymbalta, an antidepressant, to treat chronic back pain. But the data on antidepressants is also mixed. A study last fall in The Annals of Internal Medicine found that antidepressants help back sufferers, but this year a review by the respected Cochrane Collaboration, a nonprofit organization for health information, concluded there was no evidence that antidepressants offered relief.
While the quest for a safe and effective pain pill continues, Americans undergo more than 300,000 spinal fusion surgeries a year, at an average cost of $59,000 each, according to the National Center for Health Statistics. Almost as many undergo laminectomies or diskectomies to remove damaged vertebrae and disks.
For some, back surgery can be life-changing, eliminating pain and disability. But for others, it can have serious consequences. One study found that 11.6 percent of patients in the 78 spinal surgeries that were analyzed developed infections and other complications.
Newer procedures, like implants of medication pumps and stimulators, have received mixed reviews, too. The jury is still out on kyphoplasty, an outpatient procedure for patients with vertebrae fracture from osteoporosis. The doctor inserts a needle into the spine and inflates a balloon, then injects a cement, gluing the bones together. The procedure works only for some patients.
With such uncertainties, it is little wonder that many doctors have fallen back on more traditional approaches to easing the pain, like exercise or counseling. This year, the Accreditation Council for Graduate Medical Education began requiring that medical residents who want to become pain specialists study not only anesthesiology but also psychology, neurology and rehabilitative medicine.
The reality is that most people with back pain heal on their own, slowly, without major intervention. “The best treatment for straightforward back pain without a specific diagnosis is reactivating yourself to what you normally do as fast as possible,” Dr. Weinstein, the Spine editor, said.
Twist and Ouch
By Gretchen Reynolds : NY Times Article : October 28, 2007
Not long after a typically underwhelming showing by the British contingent at the Wimbledon championships in July, the British Journal of Sports Medicine published the results of a study that suggested to beleaguered English tennis fans that things are only going to get worse. In the study, researchers from the Royal National Orthopaedic Hospital scanned the spines of 33 elite adolescent tennis players, male and female, who trained at the National Tennis Centre, the club of choice for Britain’s most promising young prospects. None of the players had reported back pain. But their backs, it turned out, were a mess.
Twenty-eight of the teenagers — 85 percent — were found to have serious spinal abnormalities, ranging from cysts to fractures. Twenty-three had early-stage joint disease and 13 had herniated discs or desiccated, shriveled discs, common in septuagenarians but much less prevalent in teenagers. These kids, the cream of the next generation of British tennis, had backs 60 years older than they were.
“Tennis requires more frequent, repetitive and rapid rotation from the lumbar spine than other sports,” the authors wrote. Playing it is particularly detrimental “during the growth spurt.” High-level tennis, in other words, can be brutal on the young.
But as many of us know from debilitating firsthand experience, back problems don’t afflict just teenage tennis players. According to various studies, at least a third of all competitive football players will hurt their lower backs during play, as will a third of gymnasts and 25 percent of serious rowers. About 40 percent of divers will develop a spinal stress fracture, and many cyclists will experience constant, grinding back pain while riding. In one study, six out of seven rhythmic gymnasts — those madly grinning ribbon twirlers — reported severe lower back problems. The harshest sport, however, seems to be golf. Ninety percent of injuries to professional golfers involve the lower back and the neck, and almost 80 percent of professionals will miss at least one tournament because of back pain.
If you’re a runner, do a backbend of thanksgiving: runners statistically have a lower risk than most athletes of developing back problems. But for everyone else, the news is . . . painful. So what, if anything, can you do to preserve and protect your spine?
To build a better back, most experts agree, you need a solid core. “The core” is one of those areas of the body that coaches and athletes refer to constantly but few people can accurately locate. “It’s not just the abdominal area, as many people think,” says Vijay Vad, a sports medicine specialist at the Hospital for Special Surgery in New York City and a back-care adviser to the PGA Tour and the professional men’s tennis circuit. “To really include all of the elements that move and stabilize the spine, you have to go from your knees to your nipples. That’s the core.”
The muscles, ligaments and tendons that make up the elaborate core muscle system provide rigging for the spine. The rectus, transverse and oblique abdominals, for instance — the big muscles at the front and sides of the spine — are particularly important in stabilizing the back. So are the less familiar intertransversi, interspinalis and multifidus muscles, which link to the larger abdominal group but which rarely figure in magazine articles about washboard abs. Each of these muscles must be strong and supple if the spine is to remain stable.
Endurance is important, too. It’s perhaps the most crucial element of core health, since it keeps the stabilizing muscles and connective tissues going through a long workout or game. “You have to have enough muscular endurance to be able to maintain spinal stability throughout the entire length of an activity,” says Michael Higgins, the director of athletic-training education at Towson University in Maryland and the author of several prominent academic articles about back injuries in athletes. “Without endurance, what you often see is that near the end of a game, the muscles can’t quite control the movement of the spine adequately anymore.” Whether you’re playing four quarters of football, three sets of tennis, 18 holes of golf or riding 100 miles on a bike, if your core can’t keep up, your back is sure to let you know about it.
Many lower back problems are caused by the very athleticism that modern sports demand. “The forces involved in sports nowadays are enormous,” Higgins says. “What you see in some of these sports are very powerful athletes creating high levels of extension and compression of the spine.”
Consider the forces applied to the lower back during certain activities: The torque created by a proper golf swing can produce almost 1,700 pounds of pressure on the lower spine. Rowers can put about 1,300 pounds of pressure on their backs at the catch of their stroke. And the “peak compressive load,” as the scientific parlance goes, created by a football lineman slamming into his opponent can be close to 2,000 pounds.
Often, the muscles that produce such power are accompanied by a relative weakness and inflexibility — ever see a lineman touch his toes? — in muscle groups not being used. Sprinters, for instance, tend to have mountainous quadriceps but weaker, tighter hamstrings. The hamstrings, which, like the quads, are tied into the lumbar spine system, can’t balance the force being produced by stronger muscles. As a result, the spine loses stability.
Something similar occurs in golfers, especially the good ones. “If you’re a bad golfer, like me, and you use your shoulders to power the swing, instead of your back, you probably won’t hurt yourself,” says Christopher Bono, an assistant professor of orthopedic surgery at Harvard Medical School and the chief of spine services at Brigham and Women’s Hospital in Boston. “If, though, you’ve got a good swing, you’re probably going to hurt your back.”
Just ask Arron Oberholser, the PGA Tour golfer who has ranked as high as 22nd in the world but who has also, at the advanced age of 32, endured multiple ruptured discs in his lower spine.
“I thought a couple of times that my career might be over,” he says. “There seems to be something about the repetitive golf swing that primes you for this injury.”
Power and consistency, in other words, can be your back’s undoing. “Strength, by itself, is not the answer,” Higgins says. As the authors of the British study pointed out, those young tennis players were strong. But they were strong only in terms of their tennis muscles, particularly those in the shoulders. Compared with their counterparts in other national junior programs, British players rarely visit the weight room. They typically don’t stretch or cross-train. Instead they hit and hit and hit, repetitively, propulsively, their strokes becoming faster and sharper, even as their backs insidiously break down.
Having a strong back, you will be happy to hear, means not doing sit-ups. Ever. “Sit-ups are not healthy for the back,” Higgins says. “They can severely compress the lumbar spine.”
Abdominal crunches, on the other hand, in which you raise your head and trunk slightly from the ground without pulling yourself upright, improve back health significantly. “Crunches build core endurance and strength without stressing the spine,” Higgins says.
A complete back-health exercise regimen must include more than crunches, of course (see sidebar, right). “You need to activate and strengthen all of the muscles that circle the spine like a belt,” Higgins says. You can do this by slightly contracting your abdominal muscles during workouts. Don’t suck in your gut; that narrows the band of support around the spine. “You only need to contract the abdominal muscles by about
10 percent to get the spinal benefits of the abdominal bracing,” Higgins says.
Don’t forget flexibility, either. In 2004, Vad and other researchers led a study of 42 professional golfers and found that those with the smallest range of motion in their lead hip and lower back had the highest frequency of back pain. “If you have a loss of flexibility in the hips, the back will take up the slack and absorb more of the pressures of the swing than it should,” Vad says. “Yoga, Pilates, dance — they’re all good for core flexibility.”
If your back aches for more than a few weeks, or if the pain is acute or radiating, visit a doctor. “Most back injuries will clear up on their own within six to eight weeks, if you rest adequately,” Vad says. “Surgery is very rarely necessary, maybe in 3 to 5 percent of cases.”
Finally, don’t despair if your back hurts. For many athletes, pain has been a necessary prelude to wisdom. “Before my back injuries, I really thought this golf thing was so easy,” Oberholser says, almost wistfully. “I thought, ‘I can do this into my 50s, no problem.’ ” Now, after reinjuring his back yet again last spring, he’s in the midst of an elaborate overhaul of his swing mechanics, his strength training, his posture — in short, his entire game. “I’m being a lot more careful than I used to be,” he says. “I’m doing the exercises, following the advice. I’m really optimistic about next season, but cautious, too. I’ve learned that you have to take care of your back, because, otherwise, boy, it’ll take you down with you if it goes out.”
SUPPORT THAT LAZY SPINE:
The best exercises for strengthening your back
Entire books have been devoted to workout routines for the back. But you can save yourself some trouble by focusing on these three exercises, which work most of the large muscles in the body’s core. Do them four times a week, breathing slowly and steadily throughout.
CURL UP
Lie on your back with your knees bent. Slide your hands under your lower back to provide support; you don’t want your spine flat against the floor. Straighten one leg. Then, while keeping your neck and lower spine straight and unmoving, lift your shoulders and chest off the floor. Hold the position for about eight seconds. Repeat 10 times, then switch legs and do another 10.
SIDE BRIDGE
Lie on your side, with your legs bent at the knee and your upper hand across your chest. Bend your lower arm so that your elbow is pointing away from your chest. Slowly raise your shoulders, keeping your spine straight, and hold for 8 to 10 seconds. Repeat on the other side. After a few weeks, do the exercise with your legs straight.
BIRD DOG
Start on all fours, then slowly lift your right arm and left leg until each is parallel to the ground. Hold for eight seconds. Repeat with the opposite arm and leg. Do 10 reps on each side. Keep your spine straight, hips level and abdominal muscles slightly contracted. And don’t forget to breathe.
How to Keep Winter From Taking a Toll on Your Back
By Jane E. Brody : NY Times : February 7, 2011
This is your back speaking, and now is the winter of my discontent. With all the snow and ice and cold that have descended on much of the country, there are so many ways I can get hurt. So I want you to know what you can and should do to protect me and keep yourself out of debilitating and disabling pain, now and in the future.
This is especially important if you’ve already experienced back pain or, worse, sciatica. But even if your back has been perfectly healthy until now, it’s important to know how to keep it that way.
Low back pain, with or without sciatica (leg pain when sciatic nerve roots are pinched), is extremely common, afflicting 70 percent of people at one time or another. Next to headache, it is the most common medical complaint, and next to the common cold, it is the most frequent reason for missed work.
Winter brings on more than the usual back hazards. There’s all that shoveling — especially this year, in the East and Midwest. There are the cars that get stuck and need to be pushed to freedom. There are the icy patches, including black ice and ice disguised by a thin layer of snow, on walkways and stairways and in crosswalks. And there is the tendency to hibernate and perhaps slack off on physical activities that can strengthen and tone muscles that support the back and protect it from injury.
The following guidance comes primarily from Dr. Preston J. Phillips, an orthopedist and sports medicine specialist in Tulsa, Okla., who happened to visit New York City during the mid-January storm that brought us 19 inches of snow, giving him firsthand knowledge of what real snowbirds face.
Dr. Phillips is co-author, with Dr. Augustus A. White III, professor of orthopedic surgery at Harvard Medical School, of “Your Aching Back: A Doctor’s Guide to Relief” (Simon & Schuster; updated in 2010), an extremely helpful book complete with drawings of safe ways to move and exercise that are easy to incorporate into nearly every life.
SHOVELING
Cardiologists suggest that men over 50 and women over 60 should leave snow shoveling to younger folks. But yours truly, and many of my neighbors, pay no heed. In fact, despite my rather iffy back, I’ve found that shoveling, properly done, enhances my strength and muscle tone and actually protects my back.
The tricks, according to Dr. Phillips: Bend from your knees, not your back; don’t overload the shovel; remember that wet snow is heavier than the fluffy kind; shovel in short intervals and rest in between; and don’t twist.
Instead move your feet, put one foot forward and face the direction you’re going to throw the snow. Above all, as the doctor said in an interview, “don’t be macho — hire the kid down the street or use a snowblower.”
GETTING THERE
Allow extra time to get places. Do not run or race-walk to catch a bus or train or to get to work on time. Be especially careful on stairs; use the handrail and watch your step. If you must use a bicycle for transportation, look for cleared roads to ride on, even if the route is longer. Black ice and slush are especially treacherous for cyclists.
STAYING UPRIGHT
I’ve been appalled to see what some very elderly men and women have been wearing on their feet this winter — flimsy, treadless shoes that are herniated discs, fractured spines or broken hips (or worse) waiting to happen.
Soles of shoes or boots should grip the snow or ice. There are several products that can turn ordinary shoes into cleats. They include GripOns, Yaktrax Walkers, STABILicers and DryGuy MonsterGrips, sold in sporting-goods and shoe stores and on the Internet.
“A walking stick or cane can provide added stability,” Dr. Phillips said. And to avoid straining your back, use a long-handled shoehorn to put boots on — and a boot jack (a wood or iron device with a U-shaped mouth to grip the heel of the boot) to take them off.
PUSHING CARS
First, try to improve traction using branches, cardboard, sand or cat litter under the wheels. If pushing is required, the doctor said, “get three or more people to push the car out.”
He also endorsed a good-neighbor policy: “If you see someone having difficulty, offer to help if you can — and if you’re the one who needs help, accept it when offered.” (When my loaded shopping cart got stuck in a mound of snow at an intersection, a kind — and strong — stranger picked it up and carried it over the obstacle.)
CARRYING
When navigating uncertain surfaces, it’s critically important to watch where you’re stepping and keep your balance. Don’t carry too many packages from the store or car at once; better to make extra trips.
Also, equalize the load on both sides of your body. When lifting heavy packages from the car, first move them close to your body and bend from the knees to pick them up. If you must carry a young child, use a sling or backpack carrier. If instead the child is in a stroller or carriage, avoid sudden twists and watch for ice ahead.
CLEANING AND CLEARING
Winter, when the body stiffens against the cold, is not the best time to clear your yard of tree limbs and branches. “Unless they’re obstructing your path or are a risk to your home,” Dr. Phillips said, “leave them until the weather warms up.”
If the roof develops a leak, call a professional; climbing on a wet, icy or snow-covered roof “is a recipe for disaster,” he said.
KEEPING STRONG
Though it’s tempting to hibernate in the cold, this is no time to slack off on exercises that protect your back and your entire body, from your shoulders to your shoes.
“If you have good muscle tone over all, your muscles are better able to compensate for problems in the lower back,” Dr. Phillips said. As he and Dr. White wrote, the crucial components of a good exercise program are “regularity, trunk muscle strengthening and endurance, and palatability.”
They recommend walking, cycling (indoors or out) and swimming, in any combination, as the best all-around activities for people with back issues. Proper technique is critical; sit-ups should not be done with straight legs or feet hooked under something.
Isometric exercises that strengthen abdominal muscles can be done at almost any time: “Tighten your throat, bowel and bladder muscles; then press hard as if you were trying to have a bowel movement, and concentrate on tightening your abdominal muscles.”
By Jane E. Brody : NY Times : February 7, 2011
This is your back speaking, and now is the winter of my discontent. With all the snow and ice and cold that have descended on much of the country, there are so many ways I can get hurt. So I want you to know what you can and should do to protect me and keep yourself out of debilitating and disabling pain, now and in the future.
This is especially important if you’ve already experienced back pain or, worse, sciatica. But even if your back has been perfectly healthy until now, it’s important to know how to keep it that way.
Low back pain, with or without sciatica (leg pain when sciatic nerve roots are pinched), is extremely common, afflicting 70 percent of people at one time or another. Next to headache, it is the most common medical complaint, and next to the common cold, it is the most frequent reason for missed work.
Winter brings on more than the usual back hazards. There’s all that shoveling — especially this year, in the East and Midwest. There are the cars that get stuck and need to be pushed to freedom. There are the icy patches, including black ice and ice disguised by a thin layer of snow, on walkways and stairways and in crosswalks. And there is the tendency to hibernate and perhaps slack off on physical activities that can strengthen and tone muscles that support the back and protect it from injury.
The following guidance comes primarily from Dr. Preston J. Phillips, an orthopedist and sports medicine specialist in Tulsa, Okla., who happened to visit New York City during the mid-January storm that brought us 19 inches of snow, giving him firsthand knowledge of what real snowbirds face.
Dr. Phillips is co-author, with Dr. Augustus A. White III, professor of orthopedic surgery at Harvard Medical School, of “Your Aching Back: A Doctor’s Guide to Relief” (Simon & Schuster; updated in 2010), an extremely helpful book complete with drawings of safe ways to move and exercise that are easy to incorporate into nearly every life.
SHOVELING
Cardiologists suggest that men over 50 and women over 60 should leave snow shoveling to younger folks. But yours truly, and many of my neighbors, pay no heed. In fact, despite my rather iffy back, I’ve found that shoveling, properly done, enhances my strength and muscle tone and actually protects my back.
The tricks, according to Dr. Phillips: Bend from your knees, not your back; don’t overload the shovel; remember that wet snow is heavier than the fluffy kind; shovel in short intervals and rest in between; and don’t twist.
Instead move your feet, put one foot forward and face the direction you’re going to throw the snow. Above all, as the doctor said in an interview, “don’t be macho — hire the kid down the street or use a snowblower.”
GETTING THERE
Allow extra time to get places. Do not run or race-walk to catch a bus or train or to get to work on time. Be especially careful on stairs; use the handrail and watch your step. If you must use a bicycle for transportation, look for cleared roads to ride on, even if the route is longer. Black ice and slush are especially treacherous for cyclists.
STAYING UPRIGHT
I’ve been appalled to see what some very elderly men and women have been wearing on their feet this winter — flimsy, treadless shoes that are herniated discs, fractured spines or broken hips (or worse) waiting to happen.
Soles of shoes or boots should grip the snow or ice. There are several products that can turn ordinary shoes into cleats. They include GripOns, Yaktrax Walkers, STABILicers and DryGuy MonsterGrips, sold in sporting-goods and shoe stores and on the Internet.
“A walking stick or cane can provide added stability,” Dr. Phillips said. And to avoid straining your back, use a long-handled shoehorn to put boots on — and a boot jack (a wood or iron device with a U-shaped mouth to grip the heel of the boot) to take them off.
PUSHING CARS
First, try to improve traction using branches, cardboard, sand or cat litter under the wheels. If pushing is required, the doctor said, “get three or more people to push the car out.”
He also endorsed a good-neighbor policy: “If you see someone having difficulty, offer to help if you can — and if you’re the one who needs help, accept it when offered.” (When my loaded shopping cart got stuck in a mound of snow at an intersection, a kind — and strong — stranger picked it up and carried it over the obstacle.)
CARRYING
When navigating uncertain surfaces, it’s critically important to watch where you’re stepping and keep your balance. Don’t carry too many packages from the store or car at once; better to make extra trips.
Also, equalize the load on both sides of your body. When lifting heavy packages from the car, first move them close to your body and bend from the knees to pick them up. If you must carry a young child, use a sling or backpack carrier. If instead the child is in a stroller or carriage, avoid sudden twists and watch for ice ahead.
CLEANING AND CLEARING
Winter, when the body stiffens against the cold, is not the best time to clear your yard of tree limbs and branches. “Unless they’re obstructing your path or are a risk to your home,” Dr. Phillips said, “leave them until the weather warms up.”
If the roof develops a leak, call a professional; climbing on a wet, icy or snow-covered roof “is a recipe for disaster,” he said.
KEEPING STRONG
Though it’s tempting to hibernate in the cold, this is no time to slack off on exercises that protect your back and your entire body, from your shoulders to your shoes.
“If you have good muscle tone over all, your muscles are better able to compensate for problems in the lower back,” Dr. Phillips said. As he and Dr. White wrote, the crucial components of a good exercise program are “regularity, trunk muscle strengthening and endurance, and palatability.”
They recommend walking, cycling (indoors or out) and swimming, in any combination, as the best all-around activities for people with back issues. Proper technique is critical; sit-ups should not be done with straight legs or feet hooked under something.
Isometric exercises that strengthen abdominal muscles can be done at almost any time: “Tighten your throat, bowel and bladder muscles; then press hard as if you were trying to have a bowel movement, and concentrate on tightening your abdominal muscles.”
Spinal Stenosis:
Rate of Spine Surgery Soars
By Jilian Mincer : WSJ : February 15, 2011
A condition known as spinal stenosis is one of the top reasons older Americans seek surgery for lower back pain, and the disorder is expected to grow as the population ages.
Some orthopedic doctors are concerned the procedure has gotten more complicated than it needs to be as some surgeons combine traditional stenosis therapy with other procedures that fuse vertebrae. The more complex surgery can be beneficial for some patients, especially those with more than one spinal disorder. But it also raises the cost of treatment and increases the chances of complications, including stroke and death, recent research shows.
"It has not been shown that the more complex surgery is better [for patients with simple stenosis], but people are willing to have it done," says Eugene J. Caragee, an orthopedic surgeon at Stanford University School of Medicine, who has written on the topic in medical journals. "The marketing is relentless," he says.
Spinal stenosis occurs when bone spurs and other deposits cause the spinal canal to narrow, putting pressure on the spinal cord. Patients may experience pain or numbness in the back, legs and buttocks, and pain from prolonged walking or standing. Some people are born with the condition, but most develop it after age 50 because of normal wear and tear on the spine.
Former New York Giants quarterback Phil Simms says he never injured his back playing football. But a few months ago, the 55-year-old woke up with tightness in his back and left thigh, typical symptoms of stenosis and disc herniation. "It just got worse and worse," says Mr. Simms, now a television sports host. He says he tried several treatments including rest, physical therapy and epidural steroids, but the pain didn't ease. He found he couldn't walk more than 20 or 30 yards without stopping.
After commentating a Thanksgiving Day game, he decided "I'm not living like this anymore" and opted for surgery. Within days of the operation, Mr. Simms says the pain was gone and he was walking a mile on the treadmill.
"We're going to see a lot of this problem," says Nick Shamie, an orthopedic spine surgeon at the UCLA Medical Center in Los Angeles and a spokesman for the American Academy of Orthopaedic Surgeons. The deterioration "is a normal phenomenon that happens as we age," he says. Some 1.2 million Americans have lumbar, or lower back, stenosis. That number is expected to more than double to 2.5 million by 2020, Dr. Shamie says.
Before recommending surgery, doctors often suggest patients try taking anti-inflammatory medications and getting rest. They also might suggest acupuncture, physical therapy or steroid injections. If the pain persists for more than three months, and is shooting down the leg, doctors may then recommend surgery. The traditional surgical treatment is called decompression during which the bone, bone spurs and ligaments that are pushing on the nerves are removed.
Wellington Hsu, a professor at Northwestern University Feinberg School of Medicine, says when patients have stenosis that is limited to a small area of the spine, doctors may be able to perform less invasive surgery that uses a smaller incision and leads to a faster recovery time.
For more extensive spinal stenosis, or when a patient also has other conditions, such as scoliosis or spondylolisthesis, surgeons may also need to perform a spinal fusion. Fusing vertebrae can increase the stability of the spine, but it also can permanently limit the patient's range of motion. Rods and screws may be used to hold the bones together.
Complex spinal surgery, combining decompression and other procedures, has grown at a rate that some doctors find alarming. A recent study of Medicare patients found that the rate of traditional, decompression surgery for stenosis declined slightly in the period from 2002 to 2007. But the rate of complex surgery rose 15-fold in that period to 19.9 per 100,000 surgeries from 1.3 per 100,000. Although patients suffering only stenosis and not other spinal conditions were less likely to receive the combined procedures, these patients still accounted for as many as 50% of the complex surgeries, according to the study, which was published in the Journal of the American Medical Association.
The report said the higher rate of complex procedures increased hospital costs for surgery by 40%. The complication rate of those cases also was higher at 5.6% compared to 2.3% for the simpler, decompression surgery. Hospitals stays were on average two days longer for complex surgery, and average per-patient hospital charges were $80,888, compared with $23,724 for the simpler surgery.
"Many factors are at play, but I think the finances play an important part," says Richard Deyo, a professor of evidence-based medicine at Oregon Health & Science University in Portland, Ore., and lead author of the JAMA study. "There are some prominent surgeons who have strong financial connections to device manufacturers."
Christopher Bono, an orthopedic surgeon at Brigham and Women's Hospital in Boston, says the JAMA article doesn't explain why the surgery numbers are increasing other than "insinuating that it is because of marketing and surgeon greed." He says there could be other reasons for the increase "such as better corrections of deformities."
"The decision to do a more complex fusion versus a less complex fusion comes down to the surgeon's preference," Dr. Bono says.
Rate of Spine Surgery Soars
By Jilian Mincer : WSJ : February 15, 2011
A condition known as spinal stenosis is one of the top reasons older Americans seek surgery for lower back pain, and the disorder is expected to grow as the population ages.
Some orthopedic doctors are concerned the procedure has gotten more complicated than it needs to be as some surgeons combine traditional stenosis therapy with other procedures that fuse vertebrae. The more complex surgery can be beneficial for some patients, especially those with more than one spinal disorder. But it also raises the cost of treatment and increases the chances of complications, including stroke and death, recent research shows.
"It has not been shown that the more complex surgery is better [for patients with simple stenosis], but people are willing to have it done," says Eugene J. Caragee, an orthopedic surgeon at Stanford University School of Medicine, who has written on the topic in medical journals. "The marketing is relentless," he says.
Spinal stenosis occurs when bone spurs and other deposits cause the spinal canal to narrow, putting pressure on the spinal cord. Patients may experience pain or numbness in the back, legs and buttocks, and pain from prolonged walking or standing. Some people are born with the condition, but most develop it after age 50 because of normal wear and tear on the spine.
Former New York Giants quarterback Phil Simms says he never injured his back playing football. But a few months ago, the 55-year-old woke up with tightness in his back and left thigh, typical symptoms of stenosis and disc herniation. "It just got worse and worse," says Mr. Simms, now a television sports host. He says he tried several treatments including rest, physical therapy and epidural steroids, but the pain didn't ease. He found he couldn't walk more than 20 or 30 yards without stopping.
After commentating a Thanksgiving Day game, he decided "I'm not living like this anymore" and opted for surgery. Within days of the operation, Mr. Simms says the pain was gone and he was walking a mile on the treadmill.
"We're going to see a lot of this problem," says Nick Shamie, an orthopedic spine surgeon at the UCLA Medical Center in Los Angeles and a spokesman for the American Academy of Orthopaedic Surgeons. The deterioration "is a normal phenomenon that happens as we age," he says. Some 1.2 million Americans have lumbar, or lower back, stenosis. That number is expected to more than double to 2.5 million by 2020, Dr. Shamie says.
Before recommending surgery, doctors often suggest patients try taking anti-inflammatory medications and getting rest. They also might suggest acupuncture, physical therapy or steroid injections. If the pain persists for more than three months, and is shooting down the leg, doctors may then recommend surgery. The traditional surgical treatment is called decompression during which the bone, bone spurs and ligaments that are pushing on the nerves are removed.
Wellington Hsu, a professor at Northwestern University Feinberg School of Medicine, says when patients have stenosis that is limited to a small area of the spine, doctors may be able to perform less invasive surgery that uses a smaller incision and leads to a faster recovery time.
For more extensive spinal stenosis, or when a patient also has other conditions, such as scoliosis or spondylolisthesis, surgeons may also need to perform a spinal fusion. Fusing vertebrae can increase the stability of the spine, but it also can permanently limit the patient's range of motion. Rods and screws may be used to hold the bones together.
Complex spinal surgery, combining decompression and other procedures, has grown at a rate that some doctors find alarming. A recent study of Medicare patients found that the rate of traditional, decompression surgery for stenosis declined slightly in the period from 2002 to 2007. But the rate of complex surgery rose 15-fold in that period to 19.9 per 100,000 surgeries from 1.3 per 100,000. Although patients suffering only stenosis and not other spinal conditions were less likely to receive the combined procedures, these patients still accounted for as many as 50% of the complex surgeries, according to the study, which was published in the Journal of the American Medical Association.
The report said the higher rate of complex procedures increased hospital costs for surgery by 40%. The complication rate of those cases also was higher at 5.6% compared to 2.3% for the simpler, decompression surgery. Hospitals stays were on average two days longer for complex surgery, and average per-patient hospital charges were $80,888, compared with $23,724 for the simpler surgery.
"Many factors are at play, but I think the finances play an important part," says Richard Deyo, a professor of evidence-based medicine at Oregon Health & Science University in Portland, Ore., and lead author of the JAMA study. "There are some prominent surgeons who have strong financial connections to device manufacturers."
Christopher Bono, an orthopedic surgeon at Brigham and Women's Hospital in Boston, says the JAMA article doesn't explain why the surgery numbers are increasing other than "insinuating that it is because of marketing and surgeon greed." He says there could be other reasons for the increase "such as better corrections of deformities."
"The decision to do a more complex fusion versus a less complex fusion comes down to the surgeon's preference," Dr. Bono says.
