PhysioMonkey

Went to Crawley and had a great time.  For those I talked to who want more info then send me an email or coment here.

But to let you know I'm going on me hols from Tuesday 15th for 2 weeks so I'll not be commenting here 'til I'm back. 

Carla: I doubt I'll have time to deal with that referral before I disappear.  I will call them when I get back tho'.  If you want to try and get there earlier then have a chat with your physio and see if he/she will have a chat with them.  Sorry to be a pain but today's far busier than I was expecting.

Have fun.

Finally we get to the crux of the matter: what can you do to help yourself?

If you've read the other back articles you'll already know some of the basics.

So from the other articles you already know this (and more):

• Inactivity is generally bad.
• Most back pain will clear up quite quickly.
• It's very likely NOT to be medically concerning.
• Other people can help but they're not going to cure you.
• Using your back, even when it hurts, is NOT likely to injure you although it might be painful.

The single most important message for normal back pain (see "What is" for signs that may suggest something more than normal pain) is this:

Hurt does not equal harm.

So what to do?

I'll start when you first get back pain.

1. Rest it at most for 2 days.  Bed rest is NOT a good cure for back pain.  Neither is sleeping on a board.
2. Go and see a general doctor or get yourself to a physio. 
3. Doctors may prescribe pain killers.  Take them, you're not likely to be taking them for too long.
4. Physios will look at you when you are still, when you move and how you move.
5. Physios should give you exercises that will move/stretch your back and/or teach the correct muscles how to work.
6. You then should do them despite the fact that they may hurt.
7. If you do nothing - nothing will happen.  Actually even if you do nothing your pain may go (most does within 6 weeks remember) but you're going to be far more at risk of recurrent episodes.  Plus if you do nothing you're far more at risk of having chronic back pain, remaining off work, inability to do your hobbies, depression and more - not recommended.
8. If you treat your back as if it's delicate then it WILL be delicate.  If you treat your back like it's normal then you've a good chance that normality will return.
9. When your pain eases don't start treating your back badly again!

Stretching exercises

All of the stretches I'm about to describe are normal movements that a normal back can do, they're not designed to move you beyond your normal movement limit.  They may hurt.  But remember if you do a stretch and feel nothing, then you're not doing it right!

Exercise 1 - Rotation (twisting)

Lie on the floor (better than a bed) on your back with your knees bent and your feet flat.  Roll both knees all the way to one side - NB "all the way" means that the side of one knee should hit the floor.  Your hip WILL lift up, this is supposed to happen.  You might hear a "click" - don't be concerned about this.  Then roll all the way back to the other side so the other knee hits the floor.

This is a fantastic exercise and works well for most people. 

1 addition:  If you have pain predominantly on one side then you can tweak this exercise a little more.  Instead of rolling both ways just roll to the side AWAY from the pain.  Remember to always go away from pain.  Then return to the middle and repeat.  Don't roll towards the painful side until your pain is predominantly central.

Exercise 2 - Side bending

Start standing up.  Try to lean sideways as far as you can.  Try not to go forwards or backwards at all.  As for rotations; if you have pain predominantly on one side then make your sidebends away from that side only.  When or if your pain is mostly central then you can practice both ways.

Exercise 3 - Flexion

Lie on the floor on your back with legs straight.  Pull one knee up as far as you can to your chest.  Return to the start position.  Repeat with the other leg.  Then repeat with both at the same time.

Warning:  This may be aggravating for some problems.  If you start getting pain down the leg(s) during this exercise then stop doing it and move onto the extension exercises.

Exercise 4 - Extension

This is a difficult one for me to put in here.  For many causes of back pain this exercise is useful, very useful on occasion.  Conversely there are problems when this exercise is specifically NOT indicated.  I'll try and explain things as well as I can here but if you're still not sure then send me a mail and ask for clarification for you.  Remember that not all backs are the same!

When NOT to do this

If you are a generally very flexible person normally and your back has been giving you grief, particularly when standing or walking for a long time.  If you're habitually bending your back backwards as part of an act (eg contortionist) or if you're a dancer or gymnast then you'd be better off skipping this exercise and having a look at the "stability" stuff later in the post.

If you're still not sure then get someone to have a look at you as you bend backwards.  If they can see a "hinge" in your back when you bend then avoid this.  I'll try to get photos soon.

So what to do?

Start lying on your front.  Stage 1 of the exercise is to just prop yourself up on your forearms for a bit.  If you can do this for a while then move onto stage 2. 

Stage 2 involves half "press-ups".  Basically you do a press-up but try and leave your hips down on the ground.

With any of these exercises:

• If you start getting pain shooting down your legs then stop.
• If you start getting pins and needles or numbness then stop.
• An ache doesn't give you sufficient reason to stop!

Muscle work

Many of the chiros and physios and all of the doctors I've talked to never mention anything about muscular stability of the spine to their patients and, to my mind, this is commonly the most important factor in many people's recovery from back pain.

The spine is supported by intrinsic and extrinsic factors.  Intrinsic is the structure of the spine- the ligaments, joints etc... The extrinsic factors are the active stabilising mechanisms ie the muscles.

There are a few muscles that contribute but the most important is the transversus abdominis (TA).  You have 2 and they're in your abdomen.  Find them by finding your ASIS's (bony bits at the front of your pelvis at the top of each leg).  Move about an inch in to the middle from there and your TAs are there under the "covering".  The first thing you'll notice is that you may not feel any activity there or even know what to tense up to get them working.  

The TA will switch off if you have an episode of back pain and won't switch on again until you specifically train it.  

This means that the pain may well go away but people tend to have a history of repetitive episodes of the same pains as the poorly supported back caves in again and again.  

Now for the back you have, for the sake of simplicity, 2 kinds of muscle.  Ones that move you and ones that hold you supported.  If you lose the use of the supportive ones (this happens when you get back pain) so the body tries to adapt and overuses the "mover" muscles in a vain attempt to stop the pain happening.  Unfortunately these muscles are not suited for this task so they work even harder in a more vain attempt and so on until they give up in disgust and you get painful muscle spasm.

It's in no way a quick fix but has been demonstrated to help very effectively.  Hodges and Richardson are researchers based in Brisbane, Australia and they showed that a control group given normal exercises generally got better but had a high percentage recurrence rate (IE returning to their doctor with the same problem within a year).  The group that worked TAs as well had a much reduced return rate. Now we know that about 30% of people don't bother doing their exercises; the results could actually be even more hopeful for you if you're willing to put this type of work in.

Now for the hard bit.  I need to teach you the exercises knowing that you might struggle and not being able to see what you're doing to correct your attempts.  

Lie on your back with your knees bent and your feet resting flat on the floor.  This should be comfortable and you will likely have a slight arch in your lower back.  Some folk can easily slip a hand under their back without having to lift off the floor at all but no worries if you can't.  
Try and flatten out this arch in your back and press your lower back to the floor.  This should be a very gentle movement.  Don't change your breathing, no holding your breath.  You should also not use the "6-pack" muscle that you'd use for sit-ups.  If you feel that tense up then it's wrong.

So pull your belly in slightly, squeeze your buttocks together gently and slowly curl your coccyx (tail bone) off the floor, you can also try adding your pelvic floor muscles too (think about what muscles you'd use to slow a flow of urine down mid-flow).  Do not lift your whole lower back off the floor it's more of a slight curl up than a lift.  You should be able to hold this gently and maintain normal breathing or even carry on a normal conversation without struggling.  Another hint is to try and start the exercise at the very end of a breath out.  You're looking to have very little activity going on. If you try too hard other muscles will come and try and help, we're trying to let that NOT happen.  So work gently.

Right I'll leave that there for now.  Have a go and for more info get in touch.  I'll make a guess that either you don't find what you should be tensing or that you think you're doing it right but aren't sure.  Sorry about that but it's difficult to work without "hands-on".  The exercise should not substitute for your current method of keeping a lid on it, bu should complement it.

This last exercise is merely a starter exercise.  If you can't get this working there's no point trying harder ones.  I'll get round to putting harder exercises on the site in the future.

Hope this helps.

(Many thanks to Anwen and Danny for the photos)

Similar Posts

Back Pain - Myths and Truths

Back Pain - What Is?

Back Pain - Treatment 1 - What others can do

A letter to all:

Hello everyone!

I've had a few emails recently asking for advice which I'm always happy to offer but they seem to follow a pattern.

Here's a made-up example:

Hi PhysioMonkey

I've got a pain in my wrist from doing juggling.  What can I do about it?

Thanks

This letter doesn't really help me much.  If you're going to ask for info then please put some detail in.

For instance in this case: Does it hurt all the time or just when you juggle? Does it only hurt if you do certain things but not others?  Does the whole wrist hurt or just one part of it? And any other details you can think of.

If you don't put the detail in then I can't give you any good answers so I'll just have to write back asking for more which delays things for you.

Cheers.

Alan

[edit: reposted 4/7/06 as new info re anti-inflammatories added] 

Most injuries will be minor and may not even affect your ability to continue with whatever.

Here are some photos from a friend

• Unicycle injury.  This was a basic "turning" of the ankle.  You can see the aftermath being a decent amount of swelling, bruising, some pain and this one caused problems with walking.

• Another unicyle injury.  This was a "leg meets Muni pedals" incident.  Just some cuts with little bleeding.  It didn't need any treatment beyond some ego-massaging oohs and aahhs.

• This was a snakeboard injury.  Eye meets pavement!  Some swelling and bruising. 

Basic Advice

DO get R.I.C.E.

• Rest - Stop putting any pressure on the injured area.  If you've turned your ankle don't go for a 10km joggle.
• Ice - Whack an ice pack on it.  Don't make it too cold and don't leave it on for more than 10 mins.  The old favourite is a bag of frozen peas - be careful with this as modern freezers are far too cold for this purpose.  Wrap the bag in a thin and slightly damp towel - if the dampness starts freezing then it's too cold.  DON'T use ice if you have heart disease.  If you start to get chest pain whilst using ice then stop using the ice and go and see a doctor.
• Compression - Use a compression bandage if you have one.  Good chemists should have them.  These are often referred to as "supports"; they are not.  They simply restrict the amount of swelling.
• Elevation - If possible put the affected bit up above heart level.  Have a lie down.

DON'T do H.A.R.M.

• Heat - People like warmth but these injuries don't.  Heat promotes swelling by opening up the blood vessels in the vicinity of the heat.  Don't do it for these injuries.
• Alcohol - 2 reasons not to drink after an injury.  Firstly; if you get tipsy you're more likely to hurt it more as you drunkenly stumble away from the bar!  Secondly; the alcohol acts as a vasodilator (opens up the blood vessels) so making swelling worse.  (Incidentally this is why rescue dogs in the alps don't carry brandy - it would lead to hypothermia).
• Repeating - if you've just tried something which caused an injury don't do it again.  Does this seem too obvious?
• Massage - firstly this will be painful if someone is putting pressure on an acutely swollen area.  Secondly it also acts as a local heater leading to more swelling.  Thirdly if the tissues are badly injured then it might not take much to damage them further.  This advice relates to acute injury (ie within the first 24-72 hours post-injury)

There has been some controversy about whether NSAIDs (Non-steroidal anti-inflammatories) such as Ibuprofen and Diclofenac should be used after a recent injury.  The positives were that they reduce swelling and hence relieve pain.  The negative was that the swelling is actually rather important to healing so stopping it happen would slow down your recovery time.

Recent evidence is leaning towards the suggestion that taking NSAIDs does not really slow down healing that much.  Here's a quote from "Nonnarcotic Analgesics in Short-term Pain: Musculoskeletal Disorders" by Dr J Markenson in his review of lots of studies about this topic.

Accumulating evidence suggests that they neither delay healing nor interfere with the repair of soft tissue or cartilage following acute injury. Furthermore, in the nongeriatric population, the use of NSAIDs as short-term therapy appears to be associated with neither short-term nor long-term side effects.

This has changed my practice.  I'd previously given the advice to avoid NSAIDs.  Now I'll tell people that there has been controversy but it's leaning towards this view.

Related Posts

One-off Injuries - Major