Back Pain and Rehabilitation

							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.