PhysioMonkey

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

So what can be done for back pain?

People seem to think the answer is "Not a lot".  This is WRONG.

There are a number of areas to cover:

• What other people can do.
• What nature will do.
• What you can do.

I'll deal with these in order.

What other people can do.

These can get split even more into

1. General (family) doctors - most people's first choice.
2. Specialist doctors - orthopaedics, rheumatology and pain.
3. Physios - me and my ilk.
4. People who live with you.
5. Colleagues and bosses.

1 - General Doctors

I'll repeat this again: "A general doctor will not know huge amounts about musculo-skeletal problems".  Everyone should remember this.  You need to either get to a specialist doctor OR get yourself referred to a physio. 

What can a general doctor do?  General advice that would be useful in part for most cases of back pain.  They can also prescribe drugs for pain relief or for reducing inflammation or relaxing muscle spasm.

If you're in the UK they can also refer onwards to physio or orthopaedics or rheumatology.  I assume that's similar in other countries.

A general doctor SHOULD be able to make sure that you have nothing nasty happening.  Look at the "What is" back post to see what the worrying signs are.  If you have some of these make sure you tell the doc, don't wait to be asked.

2 - Specialist doctors

Specialist doctors, by definition, know plenty more about their area than generalists.  Having said that my experience is that specialists have egos the size of Belgium and they have their own preferred ways of doing stuff.  This means that one doc may want to operate whilst another may want to inject, a third may refer you on to a physio.  You may have noticed by now that there is rarely much agreement about specific treatments for back pain.

Some docs will suggest injections - these are not well proven to my knowledge.  Some people have good responses but that's not the norm.

Surgery - Really please avoid this if at all possible.  There is a general lay-person view that surgery will heal all their ills.  It really won't in most cases.  Back surgery should be avoided like little else.  "But there's new surgical techniques!"  That's true but the problem with new techniques is that the long-term success is very poor.  They have developed replacement discs but these invariably go wrong after a short while causing far more problems than there were before the op.

Think about what structures are in the area.  If the surgeon slightly nicks your central nervous system (CNS) then you'll be buggered (excuse the term but I don't think I'm being over dramatic).  If you wish to know how well the CNS repairs itself then take a look at Christopher Reeve.  CNS does NOT repair itself. 

I can't state this more urgently: Do NOT let a surgeon anywhere near your back until you have discussed everything about what might happen.  Ask about short-term prospects, long term prospects, chances of screw up etc...  And don't even think about surgery until you've exhausted as many other options as you can first.

Scans are another thing that people think are necessary.  They're really not that useful in 90% of cases.  They're a waste of your money or time.  In the UK whilst you're waiting for an NHS one you could be having some useful intervention.  If you pay for treatment directly you'd be better off spending less on physio treatment.

X-rays are generally even more useless than scans and not ony are they (usually) useless they increase your chances of getting cancer.  Do you still want a back x-ray?

3 - Physios

Now we're into my happy zone. 

"There is plenty a decent physio should be able to tell you about how to deal with your problem. "

Now have a look at that sentence again.  The first important word is "decent"; sadly there are poor physios just as there are bad doctors or even bad jugglers (like me).  If your physio treats you like my brother's did him then tell him to stuff his payment.  (My bro was told: "You've got a bad back mate, live with it".  Not bad from a person who supposedly spends his working life dealing with back pain.)

The next important words are "your problem".  Much as you want someone to do this for you it doesn't work like that.  This IS your problem, you are going to have to deal with it.  The physio should be able to tell you how YOU are going to get you better and then help YOU try to do it.  There is no magic trick that will suddenly take your pain away and keep it away.

First some myths:

I see people who have been to a local private physio.  He uses ultrasound, interferential therapy (electricity basically) and heat.  The heat MIGHT be vaguely useful but people are paying this guy through the nose to have their time wasted with useless treatment; they all say that they had no benefit.  Ultrasound has NEVER been shown to be particularly useful generally but it really has NEVER been used as a treatment for backs.  If you have had lots of sessions that you've paid for then go back and demand that your physio gives you your money back. 

In short - ultrasound or electrotherapy is no use for you.

Truth?  You need to work the right muscles and move and hold yourself correctly.  That's basically it but I'm sure you can appreciate there's quite some variation that needs to be addressed.  The physio should look at how far you can move into every different direction, how good the quality of that movement is, how poorly controlled the back is, the nerve supply to the legs and more.  In addition they should check for all the worrying signs as noted in the "What is" article.

You will most likely get quite a lot of explanation of what's happening and some exercises.  That's all I'll say for now.  Much of what you'll get will be an explanation of what's in the final section of this post only tailored precisely for your presentation.

4 - Those who live with you or friends that you see regularly

The first and most useful thing they can do for you is not to mollycoddle you (I like that word).  If you stop doing stuff or you're always asking for help then your back will be getting less fit and more likely to end up causing you chronic problems.  But people are generally nice and will want to help.  If you're the patient try and do as much as possible.  If you're the other person then make him/her get up off his backside occasionally to do some activity.  Just because their back hurts doesn't mean they can't do stuff. 

If you let someone sit in their own juices and complain there will be a few effects. 

• Firstly you'll get hacked off with doing everything for them quite quickly.  They are probably already grumpy because of the pain they have - you getting annoyed with them will not help.
• Second: they'll get less fit thus worsening their problem NOT easing it.  So by leaving them you're making their problem both worse and longer lasting.
• Third: their reduction in fitness will lead to increased weight which in turn leads to more back pain and less use of the right muscles.  Again this leads to increased chronicity.

Don't let someone with your basic back pain waste their time with inactivity but allow that they may not be able to help with heavy tasks.  Normal activity should not cause more injury although it may cause pain.

"Pain" is not the same as "harm".

5 - Boss and Colleagues

We spend a third of our lives working (unless you're very lucky) so work is probably the single most likely place you'll have problems.  We know that the longer you are off work the less likely you are to ever get back to work.  This should be prompting you to think about working as soon as you can.

The points for bosses are the same as for those who live with you.  Don't mollycoddle but don't expect full fitness at first.  Bosses also have legal responsibilities for the safety of all staff and if they don't think you can safely do your job they're not going to be happy about taking you back until you're better.  This leaves us in a Catch-22 situation.  You need to return to work to get active and fit but you can't until you're active and fit.  You need a good Occupational Health team or a pushy doctor.

Try and go back part-time at first.  Or go onto light duties.  Then build up to full-time and normal duties.  The process will probably cause you some pain.  Sorry that's how it goes.  If you're not doing anything stupid you're not doing damage.

Colleagues can help by not griping too much that they're doing all the heavy work.

Bosses (in the UK at least) have a responsibility to make sure all the physical tasks you do are safe.  If there is a code of practice, use it!  If there isn't, ask why not. 

Health and Safety law also requires that every worker has their own responsibility to themselves and to their colleagues.  So if you see someone trying to lift a large photocopier then it's worth suggesting they don't.  If they injure themselves and you saw it was likely and let them carry on then you are as culpable as they are.  If you specifically ordered them to do it then expect a legal action coming your way.

What Nature can do

This is easy to split into 2 parts.

1. What nature does that is helpful.
2. What is unhelpful.

1 - Helpful

Your body repairs itself - that's it really.  If you have damaged a structure then the body will heal it as well as it can.  This is why most back pain episodes last less than 6 weeks.

2 - Unhelpful

It'll make you want to do less - not good (see above).

The muscles that you need will stop working when you get pain.  This is normal for any area of the body.  If you bang your elbow your biceps won't pull as hard until the pain's gone.   But the back works slightly differently in that the muscles you need will NOT return to use when the pain goes.  You will need to specifically train them yourself.

Right this is loads longer than expected so I'm going to split the topic into 2 posts.  The next post is what you can do for yourself.

Related Posts

Back Pain - Myths and Truths

What is - Back Pain

Back Pain - Treatment 2 - What you can do