From: DrSquat@aol.com
Date: Thu, 11 Jan 1996
Subject: Info on Back Problems

Here's one from my ISSA colleagues...Dr. Arria was the chief DC for
the US Olympic team in the 1984 LA Olympics.  His back article, I believe,
will be helpful to all who subscribe.

Fred Hatfield, Ph.D.
Dr Squat

Dealing With Low Back Pain: Nerve Impingement and Inflammation

Sal A. Arria, D.C., MSS, & Charles I. Staley, B.Sc.,MSS
International Sports Sciences Association

Editor's Note: This article was adapted from "The 5 Step Back Solution," a
self-help videotape produced by the American Institute of Health Education

Note: If you have back pain, always start with an accurate diagnosis from
your chiropractor or physician. Make sure you ask him to explain what's
wrong, and then listen carefully to his recommendations. Learn as much as
you can about your condition.

Low back pain is the most frequent cause of missed work after the common
cold- it's been estimated that over 90 million people suffer with this
debilitating condtion. However, with all the knowledge and diagnostic tools
that we have available to us today, there is no reason that back pain
should continue to plague so many people.

The key to managing low back pain starts with the decision to take an
informed, active role in maintaining your health. Your back needs a little
maintenance every day- even when you don't have pain. When you visit with
your doctor, you might spend 15 minutes in an office visit. However, you
spend 24 hours a day, 7 days a week living with your back. Treatment and
therapy are important, but it's what you do for yourself when you're not
having treatment that is most important to help you live free from
re-occurring back pain.

Nerve Impingement

Nerves can become impinged or pinched by the disks, vertebrae, or swelling
of the surrounding soft tissues. When a nerve is pinched, the muscles of
the back can go into spasm, and the pain can radiate away from the spine.
There are three degrees of radiation: First degree, which is when pain
radiates to the butt; second degree, which involves pain radiating to the
knee; andthird degree, which is when pain radiates to the foot.

When a nerve becomes damaged, the muscle that it supplies (or innervates)
withers or atrophies because of the lack of nerve supply. If pain radiates
down the leg, or if you have numbness, tingling, or loss of muscle
function,  seek medical intervention immediately-the longer you wait, the
greater the chance that you'll have a permanent injury.

Reducing The Inflammation

The first step in addressing back pain is to "put out the fire."
Inflammation is often the result of the joints, nerves, or soft tissues of
your back becoming irritated, raw, and swollen. According to a recent
government study (AHCPR), the recommended initial medical treatment of
choice is usually an oral anti-inflammatory and ice. Exercise caution
however, because some people can't tolerate any type of anti-inflammatory
medication. Check with your physician before you use any drug.

While using an internal anti-inflammatory, you should also use an external
anti-inflammatory, namely ice. Flexible gel packs are best, but crushed ice
in a "zip-lock" bag works well also. Crushed ice works particularly well
for people who weigh over 200 pounds. Make sure that if you use crushed
ice, that it's really smashed up into a fine pieces-otherwise it's like
lying on rocks. Don't cover it with a towel because it just won't penetrate
deep enough to work. Instead, use a zip-lock bag.

Ice is cold and after a minute or people usually want off!  However, the
immediate pain of the ice is worth the long term relief you'll get from the
reduction of inflammation and swelling. Ice has to be cold, really cold to
be effective. Imagine the thickness of a t-bone steak and how cold you
would need to get one side to feel the effect through the other side.
That's about the thickness of the your back.

The key to using ice is staying mobile and flexible. One side effect of
cold is that it tends to make you a little stiff, so...stretch!  Do knee to
chest and pelvic rock stretches while lying on the ice. This is called
cryokinetics, or "movement  on ice." Not only does it keep you from
stiffening up but it literally pumps swelling or inflammatory edema out of
the low back as you stretch.

Sidebar: Basic Spinal Anatomy and Physiology

Our spines are composed of 24 moveable segments called vertebrae. The
primary functions of the vertebrae are to protect the spinal cord, and to
give the upper body the structural support necessary to stand. The
following three points are important to understand with respect to spinal
function:
        * Each vertebrae is designed to move freely and independently of
each other.
        * There are disks between each vertebrae that provide a cushioning
or shock absorbing function between the bones. The disks also provide space
between our vertebrae which allows room for the nerves to exit from the
spinal cord.
        * The nerves leave our spine through tiny bony openings called
foramen and then travel to all parts of the body.

Step 3: Increase Muscular Flexibility

Once the vertebrae have been specifically mobilized, it's time to stretch
the muscles of the low back and hamstrings. The best time to start is first
thing in the morning, before you get up. Do a few knees to chest and pelvic
rock stretches (please see sidebar) before your feet hit the floor. Then,
take a hot shower and stretch. As simple as it sounds, this technique has
helped hundreds of patients who have suffered for years with re-occuring
back pain.

Professional and Olympic athletes realize the importance of stretching and
flexibility, so use the techniques they use to stretch and loosen up first
thing in the morning, and then multiple times during the day to prevent
unnecessary pain or injury. We recommend (5) 2 minute stretches during the
day rather than one, 10 minute session because you usually stiffen up
throughout the day from prolonged sitting or standing. The following
stretches should take priority in your program:

KNEE TO CHEST stretches specifically stretch the muscles of the low and mid
back, buttock, and hamstrings. The key to knee to chest stretching is to
relax before beginning to pull. Gently, clasp your hands just below your
knees and pull with your arms, relaxing your low back. Hold for three to
five seconds, then release. Remember, start and end this stretch with your
knees bent. It takes the stress of the low back.

HAMSTRING STRETCHING is a critical factor in reducing low back pain. The
hamstrings (muscles in the back of the leg) connect to the bottom of the
pelvis. If they are tight it will inhibit your ability to flex or bend
forward, thus putting most of the load of bending on the low back rather
than dispersing the load and leverage between the hamstrings, gluts (butt
muscles), hips and low back.

CAT STRETCHES really stretch the muscles and joints of the low back, so
start off easy at first. Again, relax, start on your hands and knees with
the elbows locked, and then gently allow the low back to sag into an arch
(like an old horse). Hold for just a two to three seconds and then press
your low back upward (like an angry cat) and hold for 2-3 seconds.  Then
sit back on your legs and stretch your arms outreached forward, again
really relaxing the muscles of the back, butt, and legs. Hold for about 5
seconds then return to the starting position on your hands and knees and
repeat several times.
 

Step 4: Pay Attention To Your Posture

We spend most of our lives with our bodies in the three basic positions:
Sitting, standing, and sleeping (we have covered these topics in more
detail in past M&F articles). Let's cover them one at a time:
 
        * Sitting: If you were to take a survey of people that suffer with
back pain,  you would find that nearly everyone sits far too much. Sitting
increases the pressure in the back nearly two times your body weight. So if
you're a 120lb secretary you have about 240 lbs of pressure in your low
back.
   
You probably sit and drive home after spending a long day sitting at work
and then sit for dinner.  Now, your back is hurting big time so you sit in
front of the t.v slouched! Do that 7 days a week and you wonder why you
still have back problems! Even after you saw your chiropractor for an
adjustment, your massage therapist for a massage, your physical therapist
for ultrasound and heat, and finally your physician for pills. It couldn't
be more obvious: don't sit so much without moving. If you can, at work take
a few short breaks on the floor, lie down and stretch then hit the floor at
night when you come home instead of the couch.

As we stand during the day, the muscles of our back become fatigued or
tired.  Especially by the end of the day, we have a tendency to round or
hunch forward, This poor posture puts an unnecessary load on the low back
because the weight and leverage of the upper body rounding forward puts a
constant stress on the low back.

When you're standing, don't lock your knees and round forward. Instead,
spread your legs and press forward with an arch in your low back- the same
position you'd use when squatting.  Lean on an arm if you can- it helps
take some weight off the muscles of the back.

When you're lifting,  bend your knees, but it's equally important to keep
the weight that you're lifting as close to you as possible (please see
sidebar). Don't rotate or twist. Square off to what you are going to lift.
It doesn't take much weight to cause an injury.
Never outreach, lift and rotate:  It's the easiest way to tear or rupture a
disc because of the forces and leverage on the small support ligaments of
the spine. They just can't take it.

Also, prolonged standing with your weight shifted on one leg or another
creates an uneven, lateral, or side bending of the spine. This really loads
the tiny joints of our  back.

An example of this concept is a new mother.  It's tough carrying a baby
around without putting them on one hip, but try to switch sides often, and
keep the baby close to you. Don't exaggerate the sway of your back by
letting your tummy hang forward.

If you stand on a hard surface like concrete all day, the cumulative effect
of compression and the constant pounding and jarring of your spine when you
walk with hard shoes is just another variable that can contribute to your
back pain. Assess  the surface and work place you stand at all day.  NIKE
AIR�  shoes do an incredible job stabilizing the foot and cushioning the
impact on heel strike.  Nike has a wide variety of AIR� shoes worth trying.
They're designed to  really take the shock out of each step.

Nike designs their shoes to protect and support athletes who make millions
of dollars for playing sports. The same technology and material they use
can help us combat the effects of pounding and compression that we have to
go through walking and standing all day, every day on hard surfaces with
hard shoes. It's just another variable that can cause back pain that is
easily remedied.

        * Sleeping: First, don't sleep on your belly. Prolonged
hyperextension  from sleeping on your stomach causes the low back joints to
jam together and it  definitely contributes to back pain. Try to sleep on
your back with you knees bent, or if you sleep on your side and have a
small waist, use a pillow under your waist to keep the plane of the spine
horizontal with the bed.  Don't be afraid to use lots of pillows around you
- not to prop you up,  but to support you in an oblique or almost on your
side position.

Select a mattress that's not too firm but not too soft. Rotate and turn
your mattress every couple of months- if you can't afford a new mattress,
use a piece of plywood between the mattress and the box spring for added
support. We spend almost one third of our lives in bed, so if you wake with
pain, the first thing to do is to replace your existing mattress!

Step 5: Strengthen Your Back And Abdomen

The back is supported on the outside by muscles, and on the inside by
ligaments and tendons. They must be exercised to strengthen them, but make
sure you follow the previous four steps before attempting to strengthen
your back. Check with your doctor and ask him which exercises you should or
shouldn't do. If you try to strengthen your back or abdomen without
becoming flexible first, you really stand a chance of straining your back.

Think about it. If your back muscles are tight and you try to do an
abdominal exercise which requires forward flexion or bending of the trunk,
you'll strain or sprain your back.

Now comes the work. The bottom line is, if you have back pain, you must
eventually work on strengthening the surrounding muscles and ligaments that
support your back and trunk in order to keep your symptoms from
reoccurring. Just a few minutes a day will make a big difference.
  
The abdominal muscles provide approximately fifty percent of the support
for the back. You must tighten up your tummy. The area between the rib cage
and the pelvis is called the trunk. Like a giant redwood tree, you'll never
see one standing with one half of a trunk! Your trunk is composed of two
major muscle groups, the abdominal muscles and the muscles of the back. The
effectiveness of abdominal exercises is enhanced by training consistently
and having good form or technique.

Exercise the abdomen a few times a day, morning, noon, evening. Lie on the
floor instead of sitting on the couch at night watching t.v. Then on every
commercial do a few knee to chest stretches and ab crunches. It really
works! Consistent, moderate training is the key to great success without a
lot of effort or time. Statistics tell us the average person watches two to
three hours of t.v. a day. So hit the floor at night and start to
strengthen those abdominal muscles while you're watching the tube, talking
on the phone, or reading to your kids. 
    
Try to remember to tighten your abdomen throughout the day as you stand,
work, or drive. A simple thing like keeping your abs tight really does make
a big difference because it helps take the load off the back during the
day.

In the case of women, especially after having a baby, the abdominals are
weak. They took nine months to get out of shape and they'll take a few
months to come around.  If you just let them go, you'll be prone to back
pain.  For men, the beer belly that you're working on reducing sets you up
to having back pain because it pulls the spine into a sway and offers no
support for your back.

Until your abdominal muscles become strong enough to support your back, use
a belt or support. Belts increase the abdominal support by providing
support from the front of the spine.

If you have to lift for a living, or if your job necessitates loading,
bending, carrying, standing reaching all day, then use a belt.  I'm sure
you've seen workers wearing them. Over the years we've recommended belts
with great success. Recognize that using a belt isn't intended to replace
your abdominal strengthening program, but rather as a support until your
abdominal musculature gets strong enough to carry the load.

Even when your abs do get strong, it's o.k. to use a belt if you have a job
that requires prolonged heavy lifting. After all, football players,
powerlifters, bodybuilders, and weightlifters have used them for many years
to protect their backs during heavy training or competition, and they
usually have very strong abdominals. Keep the belt loose when you're not
lifting, then synch it down tight when you have to carry or lift heavy
objects.

During the acute phase (the first week or so) of back pain, we recommend
the use of a belt or support most of the time except sleeping or lying on
ice. While you're driving, sitting at work, or if you have to return to
work when you're still in pain it's o.k. to use a belt most of the day.

We can't stress it enough: the constant aggravation created by not having
abdominal support is a significant reason for an unnecessarily  prolonged
recovery after an injury.