Judy Hattle MCSP Carlisle Physiotherapy & Sports injury Clinic. Back Pain and Rehabilitation. Lower back pain affects over 24 million people in the UK every year! 90 percent of adults will suffer neck and back pain in their life. Many of us will have suffered with back or neck pain at some stage in our lives, whether it be just a niggle or more severe symptoms. While the incidence of this is increasing, the average age of the sufferer is decreasing. Neck and back pain treatment is becoming very important. There are many different structures and tissues that can produce pain in the spine, e.g. 'slipped disc' pressing on a nerve, a joint strain or a 'pulled muscle' and there are as many different causes. It is often difficult to know the exact structure at fault, as we cannot “see inside”. However, clinical experience shows that the vast majority of patients suffer from a gradual onset of symptoms that are fundamentally due to repeated tissue overload caused by the following: Sustained bad posture e.g. slouched sitting Repeated poor movement patterns e.g. bending over from the low back Sedentary lifestyle i.e. sitting all day and becoming gradually deconditioned not exercising frequently enough or at all Patients also experience low back pain from traumatic injuries/incidents. These can be harder to rehabilitate due to the nature of the injury and the forces applied at the time of injury. Treatment approaches should address all aspects of the underlying cause(s) and not just the usual symptom relief. This includes ergonomic workstation advice, postural re-education, education of the client as to the diagnosis and ensuring a maintained prognosis. Judy Hattle MCSP Carlisle Physiotherapy & Sports injury Clinic. Rehabilitation of low back strains We recommend seeking professional advice before beginning rehabilitation. Aims of rehabilitation: Reduce pain and swelling. Modify activities to reduce stress on the lower back. Improve mobility and flexibility of the back. Strengthen any weaknesses. Treatment/Advice: Apply ice packs for 20 minutes at least 3 times a day but as often as every two hours if needed. This should be applied for the first 48 hours after injury, but can be applied as long as benefit is being gained from it in the later stages of treatment. Rest. If necessary in bed but bed rest is to be avoided if possible. Encourage early mobilisation within the limits of discomfort. (A little but often.) Try and assume a position or posture that is not painful. The psoas position may be comfortable (lie on your back with your feet resting on a chair or similar so the knees are at 90 degrees). The acute stage of an injury may last up to 48 hours if you have looked after yourself. If not it may be longer. Modifying activities to reduce stress on the lower back: Many back injuries are not caused directly by sport but by every day activities such as sitting badly or lifting with poor technique. Poor sporting technique needs to be identified. Sitting in a slouched position may feel comfortable but it is taking the stress off the back muscles and onto the ligaments. Eventually the ligaments will become damaged. Always try to sit upright with a natural curve in the lower spine rather than slouching to flatten the lower spine. Judy Hattle MCSP Carlisle Physiotherapy & Sports injury Clinic. When lifting heavy objects try to bend the knees rather than the back. Contract the stomach muscles when lifting and try to keep the shoulders and back upright rather than bent over. Again, try to maintain a natural curve in the lower spine. The spine is far stronger when in it's natural position. If you compete in a technical event that puts stress on the spine then ensure you use the correct technique. See a good coach if you haven't already done so. Improving mobility and flexibility: Once the back has suffered a strain, the muscles are likely to go into spasm, weaken or tighten up. In addition there may be scar tissue where the injury has healed. The scar tissue will be inelastic. The result of all this may mean an imbalance of muscles in the back resulting in further problems. It is important to improve the mobility of the spine and flexibility of the muscles involved and return them to their original condition. Mobility exercises can begin as soon as pain will allow. Exercises should be done 3 times a day for the first 5 days of rehabilitation and at least on a daily basis after that. Strengthening exercises: Strengthening exercises can be done on a daily basis as soon as pain will allow – within the limits of discomfort. This may be 48 hours after injury or up to a week or more depending on severity. In general the abdominal muscles or stomach muscles are usually in need of strengthening. Good abdominal strength can take up to 30% of the stress off the lower back. Other exercises to strengthen the lower back muscles are also important but strengthening the back muscles in isolation when they are already tight can increase problems long term. Increase the intensity or number of repetitions of each exercise gradually, when you can comfortably manage the current workload. There is no need to increase every day! Strengthening exercises should be combined with mobility and flexibility exercises and continued long after you feel the injury has healed. Judy Hattle MCSP Carlisle Physiotherapy & Sports injury Clinic. MUSCLE STABILITY EXERCISES FOR THE BACK Research has shown that specific exercises can be effective in relieving back pain and restoring normal function. These exercises are most effective for what is called 'mechanical low back pain', where poor postural habits and the pain resulting from disc problems cause the problem. Once the correct technique has been mastered these exercises are very easy to do. They are not too vigorous and they can be done by people of all ages. The principle behind the exercises is that if certain specific muscles can be recruited or contracted, the spine will have much better support. This prevents postural faults, which can predispose a person to back pain. In order to understand how these exercises are effective it is necessary to have a brief introduction to how the back is supported by muscles. The first muscle we are concerned with is called Transversus. This muscle arises from the middle of the tummy and goes right around the midriff, attaching itself to the spine. The Transversus muscle acts as a natural corset and provides stability for the lower back. The second muscle involved in this exercise programme is the Multifidus. This muscle lies deep in the spine and attaches in between each vertebra. When it contracts it increases the stability of the spinal column. If you can contract the Transversus muscle, the Multifidus muscle is also contracted automatically. This improves spinal stability and can relieve back pain. Judy Hattle MCSP Carlisle Physiotherapy & Sports injury Clinic. SO HOW DO YOU CONTRACT THE TRANSVERSUS AND MULTIFIDUS MUSCLES? The most effective way to learn how to contract these muscles is to kneel on all fours. Once in position, relax and allow the stomach to sag down with gravity. To contract Transversus now, all you need to do is very gently pull in your tummy so that your belly button moves closer to your spine. It is important not to contract too hard; otherwise you will be using muscles other than the ones we are concerned with - don't contract your 'six pack' muscles. Also, don't confuse this exercise with breathing in and sucking your tummy in - you should be able to hold the contraction while continuing to breath and have a conversation. It is difficult at first but once you have mastered the technique it should become second nature. The contraction should be held for 5 seconds and repeated 5 times. Then, as your technique improves, increase the contraction hold to 10 seconds. Eventually you should be able to hold the contraction indefinitely. At this stage you should be able to move to different positions, such as sitting in a chair or standing up, and still be able to contract the deep stabilising muscles. Although it seems strange at first, once the muscles have been recruited, you will not have to concentrate on them and they will contract automatically - thus improving your posture and spinal stability. It is also important to regain the full mobility of the spine. For the spine to function normally it has to have normal movement as well as good stability. Judy Hattle MCSP Carlisle Physiotherapy & Sports injury Clinic. Prevention In order to avoid a recurrence of the problem it is important to take better care of the back in future. An understanding of good posture is necessary to achieve this. Viewed from the side the spine consists of a series of curves: These curves increase the load-carrying capability of the spine. The lumbar part of the spine consists of a forward curve and as long as this is maintained, posture will be reasonably good. It is important that this improved posture is maintained during all activities, particularly when sitting for long periods - slumping should be avoided. A lumbar roll placed at the bottom of the back can be effective when sitting. Driving for long periods should be avoided. In the long term, good posture is maintained by increasing the muscular stability of the spine. This can be achieved through specific exercises.