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Back and Pelvis Articles

Back Program

The back preventative program is designed to correct posture, improve flexibility and build strength in the suporting structures of the back. Always check with your physician if the pain is persistent or you fall into one of the categories previously mentioned in the brochure. Aerobic fitness which includes things like walking, cycling, and swimming has been proven to improve and prevent back pain. Your goal is to exercise for 25-40 minutes 3-4 times per week. Tight structures increase the stress on the back structures. All stretches should be performed in a static slow non painful manner.

Each stretch should be held for 30-60 seconds and repeated twice on each side. The goal in strengthening is to restore the strength or muscle imbalance which has lead to the injury and pain. It is important to strengthen the muscles in the front and the back of the body as well as the pelvis and leg muscles since they all impact on the back. The program should be performed at least 5 times a week.


The Back
What do Mario Lemieux, Joe Montana, Randy Johnson, Fred Couples, Wendyl Clark, You, and 95% of the population have in common. Back Pain!!!! The most common ailment in the body to be affected. Every year more than 1,500,000 Canadians seek help from a medical person for back pain. And if that number seems high it is reported that only 15-20% of people with back pain seek medical help. It is a rare person that has not experienced back pain in their life. I personally have witnessed severe back pain and one of the rare days that I have not been able to work was when I was crippled with back pain where I could not move two feet without severe pain. The back is the centre of the body and if it is hurt then the rest of the body can not function or if it can, cerainly not well. Although most back pain comes on slowly over time, it can also come on very quickly where one minute you feel fine, only to be felled by severe back pain a cough or sneeze later.

Not only is back pain a pain for the individual, it is a major problem with productivity. To stress the magnitude of the problem, back pain is the major cause of disibility of people off work. It costs the system BILLIONS of dollars in treatment for their pain not including the money lost in decreased productivity. Athletes are no exception to this epidemic. This is why you hear so often that athletes can not play or their play is affected by back pain. Over the next few columns I will discuss the most common causes of back pain and more importantly how to treat back pain. As with any problem the more you understand about the problem, the easier it is to treat the problem. So far all of this column has been doom and gloom. But do not despair. As bad and disabling as back pain can be it is almost always self limiting.

This is why you rarely see back pain as a career limiting problem. In fact I am always surprised how fast we can get our athletes back playing after seeig the when they can barely stand up. The key part of dealing with your back problem is to take control of your back and do your best to prevent further problems. So you are not alone, in fact far from it. Because back pain is so common everyone has a quick cure fro back pain. There are no quick cures. We have to learn from the past and what has happened to your back. We can not see or predict the future, but what we have is the present. We can now in the present prepare our back and control what is going to happen in the future.


Back Pain Anatomy

In the last column I reported how common back pain is. This column will get into the meat of what causes back pain. To understand what causes back pain, the first thing is to learn a little bit of the anatomy of the spine. Once you understand the anatomy of the spine, you can begin to understand why the back is co complex and what can go wrong. The back is made up of 24 building blocks called vertebrae which support the body. There are seven cervical vertebrae, twelve thoracic vertebrae, and five lumber vertebrae. The majority of the problems stem from the lower lumber vertebrae where we see most of our problems. The vertebrae sit on top of each other separated by the spinal disc. On the back of each vertebrae there are two joints on each side called facet joints. Half the weight of the body goes through the body of the vertebrae and the disc while the other half of the bodies weight goes through the two facet joints.

The spine has three healthy natural curves. This allows the spine to acts as a shock absorber. As a load is placed upon the spine the curves bend to dissipate the force. If for any reason these curves are lost then there is a dramatic increase of force through the individual vertebrae and disc. The facet joints are true joints very similar to the joints in your fingers. They allow the back to bend forward and backward as well as rotate from side to side. They are placed under the most stress when the back is bent backward especially with some rotation. Like any joint it is easily sprained and because there is so much stress through these small joints they are more prone to degenerate. The most talked about structure in the back is the spinal discs. These shock absorbing disc sit between each vertebrae. They are made up of a softer centre and a realatively hard outer shell.

They also provide a lot of stability to the lumber spine. Problems usually start when the outer annulus breaks down from injury and aging. The muscles and ligaments around the spine are crucially important. There is a long ligament that runs down both the front and back of the spine. They stabilize the spine and like any ligament around any joint in the body they can be sprained and cause problems short and long term. The back muscles are important to support the spine and the abdominal muscles are also connected to the lumbar back tissue and have a very important role in the health of your back. It is these muscles and ligaments which we can have the most effect on to ensure a healthy back. The messages from the brain to the body are carried in the spinal cord. The spinal cord runs down through and is protected by the vertebrae. At each vertebrae there exits a spinal nerve. Often the spinal nerve is injured or irritated as it leaves the vertebrae. The spine is a very complex structure which can easily have problems. Now we know the anatomy we will discuss what can go wrong in the next column.


Back Pain The Causes

Yesterday you were feeling great. You wake up in the morning all envigorated to go. You go out to do some gardening that has been waiting for a few weeks. Everything is going great until you lift a heavy bag of grass and you fee a sharp pain in your back. You go lie down and the back pain just gets worse over the next few hours. What happened? There are very few people that have not suffered from back pain. As we saw last column the back is a very complex structure. While there are many times that we can determine the exact cause of the pain, the fact is that more often than not we not make a definitive diagnosis. This leads to a lot of frustration for the patient and the medical personal. We can try and categorize back pain into a few categories. They are not mutually exclusive and there is a lot of overlap of problems that leads to the pain. MECHANICAL BACK PAIN Most back pain falls into this category.

The pain is vague and not specific to any structure. It is usually do to a dysfunction of the supporting ligaments and muscles. The stress to the back structures causes the pain. it is often referred to as repetitive lumbar muscle strain, but this simply does not occur. The predisposing factors for this pain vary with the age group. As adolescents grow the bones grow faster than the muscles and ligaments. This leads to tightness and weakness of the structures supporting the back. With increased activity such as athletic participation there is increased stress on the back structures and pain ensues. As we get older a different process takes over. The back naturally starts to degenerate after about age 20. If we do not keep the back in shape the muscles get tight and put stress on the back structures. Combine this with the weakness of the muscles supporting the spine and we have a situation where there is either an increase in abnormal movement between the vertebrae or a decrease in the normal functional movement between the vertebrae.

Often these two occur at the same time in different parts of the spine. LUMBAR STRAIN It is not uncommon to strain the large muscles in the back. This usually occurs in a quick violent movement in sports or at work. Like any other muscle strain in the body these are self limiting in a few weeks. FACET JOINT SPRAIN The facet joints are the two small joints between each vertebrae. They can be injured with stress on the joint. Just as you would jam a finger and have a sore joint(we almost al know how painful and for how long these are) you can jam these joints in your back. It is just more common in your back as there is a lot more stress going through these joints than in your finger. Classically they are injured with hyperextension of your back and aggravated by the same movement. DISC HERNIATIONS This can be the most severe of the back problems. People with back problems will often say that they have ""slipped a disc"".

This disc never actually slips. The disc is the soft disc between the two vertebrae. Most of the problems with discs occur in either the disc between the lower two vertebra and the disc between the lowest vertebrae and the sacrum. As we age the outer rim of the disc can start to dry out and crack. The softer centre of the disc can ooze out through the crack. If it oozes out far enough it can press on the nerve root exiting off the spinal cord. The more the nerve is compressed the more severe the symptoms will be. There will be pain down the leg(sometimes with not even pain in the back). There can also be numbness or tingling in the leg and weakness in the muscles supplied by the affected nerve. In the worst case scenario you can loose control of your bladder or bowels. Disc problems usually occur in the 20-50 year old age group.

DEGENERATIVE BACK DISEASE Degeneration of the lower back is a completely normal process. If we look at ALL backs as they age, there will be evidence of degeneration which will get worse as you get older. Therefore if someone tells you after looking at your X-rays that you have a degenerative back and have to severely limit your activates, get another opinion. Now, after saying that, as your back degenerates it can cause problems and pain. Obviously, it will not function as efficiently as it once did and it will put stresses on the vertebral segments. Both the disc-vertebral joint and the facet joints will be affected. It just may be that at any particular time one of the two may be giving you more symptoms.

At the severest there may be significant narrowing of the spinal canal compressing the spinal cord and/or the openings where the spinal nerve exists may be narrowed such that they are compressing the spinal nerves. These two scenarios while not common, may require more definitive treatment in the form of surgery. OTHER CAUSES There are other causes of back pain which must always be thought of. Abdominal and pelvic problems, especially the kidneys can cause back pain. An aneurysm(widening) of the aorta(main thick artery suppling blood to the lower body) can cause back pain and is an emergency. Other local causes of back pain include tumors and infection. We have now learned the major causes of back pain. The next column will discuss the treatment of back pain.


Treatment Of Low Back Pain
The back is a very complex structure. While we can often be very specific about what exactly is causing your back discomfort, more often than not we can not. After taking a careful history of your problem and a thorough examination we usually have a good idea about your back problem but NOT a definitive diagnosis. The cause of your back pain is usually a combination of the above mentioned factors. If the back pain is persistent or the nature of the problem is serious then we will do investigations to confirm or help to delineate the problem. This may include the X-rays, CAT(Computerized Axial Tomography) scan, Nerve conduction studies(EMG), and MRI(Magnetic Resonance Imaging). Ultimately the key is to control the acute episode and then follow a program to do everything you can do to eliminate the pain and prevent future episodes of pain.

MODIFY ACTIVITY Only the severest of back pain patients require complete bed rest, and even then it has been proven to be detrimental to subject yourself to more than a few days of bed rest. It is prudent to modify your activity so as not to aggravate your back problem. What you have to avoid will depend on the exact etiology of your pain. Often for example sitting is hard in patients with disc problems. Therefore these people avoid sitting for long periods of time and certainly must have a good support and posture while sitting.

ICE, HEAT, MASSAGE In the acute episode where the back muscles are in spasm, icing for 15-20 minutes every couple of hours can be very beneficial. Remember to always protect your skin from the ice with a paper/tea towel to avoid frostbite. Once the spasm has abated, heat and massage will be better to increase mobility and relieve stress on your back. MEDICATION Medication is often used in the acute phase to reduce the pain and inflammation. This should never be needed on a long term basis.

PHYSIOTHERAPY Therapy is perhaps the most important part of the treatment in the early stages. The therapist can help differentiate the cause of the pain and initiate the appropriate treatment. The therapist will then design a long term treatment program for you to avoid further episodes. A good generalized program that you do on your own is the key. The goal is to make you independent where you control your back as opposed to make you dependent on medication or a specific recurrent treatment.

WEIGHT There is no doubt that if you are overweight there is significant more strain on your back. Every pound lost towards your ideal weight is beneficial.

LIFESTYLE There are many things you may do during the course of the day that can aggravate your back. The most important thing is to learn how to sit, stand and sleep properly. The other important component is to learn how to lift properly. Whether you lift at work, at home, in the garden, or your children, you can take a lot of stress off your back if you lift properly. It has also been proven that regular aerobic exercise such as walking, cycling or swimming can help eliminate back pain. SURGERY Surgery is only very rarely required for back problems. Even then surgery is only performed when there is a specific problem that does not resolve with conservative measures. The best thing to do is to see your physician to try and get a clear a diagnosis as possible and then do your best to get in to back shape and enjoy your life.