Y O U R BACK BOOK. Your homework: Self care for low back pain OPTIMUM PERFORMANCE THROUGH MOVEMENT

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1 OPTIMUM PERFORMANCE THROUGH MOVEMENT Providing education and physical rehabilitation services since 1990 w w w. o p t m t h e r a p y. c o m Y O U R BACK BOOK Self care for low back pain Your homework: OPTM Sports & Physical Therapy, Inc

2 Chronic low back pain (LBP) is the most common musculoskeletal problem. LBP usually responds to physical therapy, activity modification, and the passage of time. The good news is that approximately 90% of acute LBP resolves within 6-12 weeks. 60% experience recurrent symptoms. Poorly conditioned bodies, poor posture and body mechanics and various psycho-social issues predispose us to pain. Therefore, there is much we can do to reduce the experience of low back pain. We also need to be aware of the health of our nervous system and think positive thoughts about our recovery. A healthy life: Good posture is good for our body. Our body parts all work together. When attempting to do something healthy for one part, we should ensure that what we are doing is healthy for our whole body. The healthier you are in general, the more resilient you will be when you are ill or injured. You will improve your stress tolerance and your recovery from painful episodes will be enhanced. Your general health and emotional well-being are essential to your recovery. Recovery is not a light switch, it is more of a rheostat. You improve a little at a time. Every day you need to remind yourself to do good things for yourself: eat the right portions of good food, get plenty of sleep (your body needs energy to recover, so don t cheat on your sleep. Get at least 7-8 hours every night) and think positive thoughts. You will recover, but it is a journey. Healthy advice: 1. Modify your postures and activities to keep your spine healthy. 2. Change positions frequently and minimize sitting to avoid static stress to your spinal tissues. 3. Move daily. Include walking and a few exercises as instructed, to keep your body strong and limber. If standing is comfortable, try standing at least 60% of your day. 4. Unload your spine by elongating it like a spring. 5. Eat a healthy diet and maintain a healthy weight. 6. Get 7-8 hours of sleep daily. 7. Improve your health with positive thoughts and meditation. Use your exercise time to clear your mind and enhance your immune system. 2 OPTM Sports & Physical Therapy, Inc.

3 Controlling Your Pain: Think positively about your future! Body Mechanics: Try to move primarily from your hips and knees in order to use your big joints and muscles when performing daily activities such as picking up an object from the floor or bending over to brush your teeth. Face objects you are lifting, bend your knees and keep your back relatively straight. Timing of activities: Be careful with activities first thing in the morning. Minimize forward bending, slumped sitting, lifting, sit-ups, and stretching your hamstrings for the first 1-2 hours of the day. If you are advised to do these activities, do them later in the day. If you work out in the morning, organize your program to do these at the end of it. It is always best to do spinal flexion activities later in the day. Arch and sag is good to do to warm up your spine in the morning. Arch Sag Hold each position seconds, repetitions. Power Leg: Your physical therapist will examine you to determine which leg will be your power leg. This is the leg which you will use for support and strength functions. The use of your power leg decreases the stress on painful tissue and may be the most important aspect of proper body mechanics and recovery. Your power leg should be under you when moving from sitting to standing. It should be forward when going down or coming up from the floor and when bending forward. Use your arms for extra support and to relieve stress to your back. POWER LEG #1 #2 #3 3 OPTM Sports & Physical Therapy, Inc.

4 Lifting: Keep the object as close as possible and in front of your body. Remember to bend your knees and lift smoothly when picking the object up. Avoid twisting or picking items up from your side during lifting activities. The most important aspect is to face the object to be lifted. START #2 #3 AVOID THIS! Carrying: Carry a portion objects at waist level and close to your body. Try to balance your loads. Divide the load in half and carry in each hand or carry the entire load in front of your body. Physical activity: If you have not exercised or performed physical work for longer than 5-7 days for any reason, illness, vacation, lazy, it is important to gradually work back up to your prior level of activity to restore resilience to your spine ligaments and muscles. Give yourself 1-2 weeks to get back into shape. 4 OPTM Sports & Physical Therapy, Inc.

5 Standing: Keep your knees unlocked to relax your back. Standing in the ballet 3 rd position, with one foot turned out 45 degrees and the other foot s heel at the instep of the first, also turned out 45 degrees will allow you to stand more comfortably. The important issue is to unlock your knees, which allows your back to relax. You may try standing with a foot on a step. If you have discomfort with standing, stay ahead of the pain with these postures. If your back gets sore from standing, try the activities to counteract extended positions. Counteracting extended postures: a. Sit, squat or lie down with a small towel under your back w/ knees up on a pillow and do some unloading if you are really sore. b. Standing with 1 foot up on a step. You might try leaning forward on your knees 5 OPTM Sports & Physical Therapy, Inc.

6 Sitting: the proper position will make a big difference in your comfort and protect your spine. Fortunately, the same positions which are good for your low back are also good for your neck. If sitting is uncomfortable for you, try the flexion counteracting movements. a. Periods of sitting > minutes are stressful for you even in the best of chairs or positions. You need to get up to move every 30 minutes to vary the stresses on your body. One position may be more comfortable than others, but remaining static in that one position is not optimal. b. If you sit for many hours each day, get up every minutes for 1 minute. Stretch your arms up to the ceiling, squat down and up, take some deep breaths and walk around. c. You need to walk and move around for 5-10 minutes prior to beginning physical work if you have been sitting for more than 30 minutes. d. AVOID SLUMP SITTING: use a pillow or towel to support your spine. Perched sitting, with your hips to the edge of the chair and higher than your knees and your feet under you is a convenient method of supporting and protecting yourself. It isn t about being vertical but rather avoiding the slumped, flexed spine position. Control your spine position by controlling your pelvis position. Find your pelvic position which straightens your spine and is most comfortably supported. Healthy positions for our low back are also healthy for our neck and shoulders. e. Recliner: Keep your back supported: Sitting in bed to read or watch TV is generally not a good position for your back or neck. We prefer that you avoid this. Straight Avoid Slumped f. Car seat: tilt the front of the seat downward so that the front is lower than the rear portion of the seat. Avoid bucket or soft seats. A Sacro-Ease car seat insert may be beneficial. Recline the back about 20 degrees. g. Couch: Place pillows behind your back for support and under your pelvis to prevent sinking into the couch. If you are sitting up, avoid having your legs straight out or dangling freely. Your feet need to be in contact with the floor or a support stool. 6 OPTM Sports & Physical Therapy, Inc.

7 Counteract Flexed Postures by using extension actions will allow your body a chance to recover from sustained spinal flexion. 1. Walking with your arms up for steps 2. Bending backwards times every hrs. 3. Rocking your pelvis up / down over a roll. Ensure that you relax completely downward. The down position is the important movement reps every hrs. 7 OPTM Sports & Physical Therapy, Inc.

8 Head Head back, chin tucked, ears, shoulder, hips aligned Eyes Level with top 1/3 of screen Document Holder Adjacent to and at same height as monitor Neck Use headphones. Do not cradle phone between head and shoulder Elbows At sides slightly more than 90 degree bend Chair Fully adjustable chair with lumbar support in small of back Chair Height Keyboard Same height at elbow with wrists slightly bent. Keystroke gently Mouse Adjacent to an at same height as keyboard Hips slightly more than 90 degrees, feet flat on floor Take breaks every 30 minutes 8 OPTM Sports & Physical Therapy, Inc.

9 Computer Use Posture o When viewing the computer screen, make sure your head is tilted slightly downward looking directly forward o Your shoulders and arms should be in a relaxed position by your side. o Your elbows should be bent at a 90 degree angle when you use the keyboard. Keyboard/Pointing Device o The home row keys should be positioned directly in the center of the trunk of your body. o The keyboard height and slope should be easily adjusted. o The pointing device (mouse) should be within close reach and at the same level as the keyboard. Chair o The chair height should be adjusted so feet are flat on the floor. o Can use a stool to support your feet if chair will not lower enough for you o Hips should be as far back in the chair as possible. If the chair is too deep, get a smaller chair. o The chair back should support the back from seat to shoulder blades. o The chair backrest height should be adjusted to provide maximum support. o Seats should be long and wide enough to support the hips and thighs and the front of the seat should be slanted a little downward. o The chair should have armrests so your arms can rest comfortably. Computer Screen o The top of the screen should be slightly below eye-level. o The screen should be at the proper tilt and height so you can view it without raising or lowering your chin. o If you wear glasses or bifocal lenses, the screen should be at an appropriate height for viewing without raising or lowering your chin o The screen should be approximately an arm s reach from you. o Documents should be placed on stands beside the monitor. o Avoid rotation as specified by your therapist. Laptop or Tablet o All of the same ergonomic principles should be applied when using a laptop or tablet. o Avoid working with laptop or tablet in your lap. o May want to use a separate keyboard to achieve appropriate monitor and keyboard heights. 9 OPTM Sports & Physical Therapy, Inc.

10 Rest: Complete rest in a comfortable position may be helpful for the first two days. Then, intermittent rests combined with guided activity. Long term bed rest will cause more harm than good. Remaining relatively activity with attention to provocative positions is best for your recovery. Changing positions can rest tissues while you continue to work. For example, standing will rest structures that are stressed during sitting, walking will rest tissues stressed by standing still. Sitting also may allow tissues to recover, but be careful to avoid sitting in a slumped position. If you want to sit to recover, it is best to recline. Changing positions every minutes provides a healthy change of pace and allows structures to recover from static stresses. Prolonged flexion can irritate your symptoms. Take 10 minute breaks every 30 minutes from activities which involve repetitive bending, such as yard work. Allow your back to recover from each session by changing to an activity which doesn t involve bending. DO NOT REST BY SITTING. You may want to lie down, do the flexion counteracting movements or walk. Resting positions are important. Since the average individual spends 8 hours sleeping, it is important to be in a position that is minimally stressful to the low back tissue. If you re having an acute flare up of pain, resting several times throughout the day, using good positions will help control your pain. The pictures below illustrate some strategies. 10 OPTM Sports & Physical Therapy, Inc.

11 Sleeping: Beds: The sleeping system includes the mattress and the pillows and how they work together. A somewhat firm mattress is generally preferred over a soft mattress. Sleep in different beds in your home to determine if one is more comfortable. When choosing a mattress, please be aware that the soft ones always feel better in the short period of time you have to test them in the store, but may not be the best for you. A supportive bed which is softer where your bones are most prominent, e.g. shoulders and hips would be ideal. European Sleep Works, (which is a good website regarding sleep issues.) does make this type of bed system. If your neck or back pain is worse in the morning and better when you move, then your sleep system, or your position during the night is not right for you. Pillows should be used to support and position your body for maximal comfort. Generally, for your neck, if you have a firm mattress, you need a slightly larger pillow. This may depend on your sleeping position. Be careful, most people use a pillow which is too big for them. You want to support your neck but not force it into uncomfortable positions. Avoid propping your head up when you are lying down. If you have neck pain, the type of pillow which may be helpful for you may change as your neck pain changes. One that supports your neck curve may be helpful when your neck is sore, but it may become uncomfortable when your neck pain improves. Ice or Heat: Ice is very effective in controlling pain and minimizing swelling. It should be used for minutes as often as necessary (at least 2-3 times per day). Ice is best to help relieve acute pain (especially the first 48 hours after the onset of pain). Do not apply ice directly to skin. Cover it with a towel first. Heat is more helpful for chronic conditions (pain that has been occurring for at least a couple of months). It is useful in relieving muscle tightness, soreness, and chronic pain. Use for minutes as needed. Avoid sleeping with it. Corset: Using a corset may reduce your low back pain. You can wear it as long as it is comfortable. Position the corset down over your pelvis and lower spine. Wearing it like a belt does not give you adequate support. Proper fitting is essential in order for the corset to be beneficial. You may need to wear a corset when performing any heavy work. Medication: Use prescribed medication as instructed by your physician. If you are relying on "over the counter" anti-inflammatory medication such as Motrin, Ibuprofen, Aleve, use as directed. If you have high blood pressure, gastrointestinal problems, or are taking anticoagulants, consult with your physician. 11 OPTM Sports & Physical Therapy, Inc.

12 Unloading Your Spine: Unloading or traction of your spine eases your spinal stress caused by compressive loading. Think of your spine as a spring with your head at one end and your pelvis at the other end. If you want to stretch a spring, you elongated it. There is little need to bend your spine much to stretch the muscles. If we elongate our spines, we do stretch some of the muscles and also we unload the compression forces, or the result of various angles of compression. It also allows the spine muscles to relax by giving a gentle stretch. This is much better than bending forward to stretch your spine. Traction can be performed in several convenient ways. Perform the traction as often as necessary to reduce low back pain. Dosage is determined by your body s response to the traction. If it feels good, it is good and if not, it could aggravate your symptoms. How much force you use and how much time you spend in traction is determined by how it feels to you. When you feel good, then stop. You have had enough. If you hold for too long or use too much force, you can irritate your back. 12 OPTM Sports & Physical Therapy, Inc.

13 Common medical terms associated with low back pain: Don t become your medical diagnosis! The following are some terms you may hear, but your well-being may not be directly related to abnormal anatomy. Many people have abnormal findings on imaging and have no symptoms. As your symptoms subside, corresponding anatomical changes probably will not occur. Pay attention to the activities which aggravate and relieve your symptoms and how you think about your pain, not your diagnosis. We can alter your health and comfort and you will get better! Stenosis: This is the narrowing of the canal (s) through which the nerves pass out of the spine. Central stenosis may be congenital or caused by a structure encroaching on the central canal, such as a central disc protrusion, bony spur or ossification of a ligament. Lateral stenosis involves disc material or bone spurs which press on the nerves. This is a degenerative change which usually occurs after the age of 60. Spondylolisthesis: This refers to the forward slipping of one or more vertebra on the vertebra below it. This can cause disruption of the discs, facet degeneration and pinching of the nerves. The spine loses its stability when this occurs. Degenerative spondylolisthesis does not involve a fracture and is a progressive degenerative condition, often resulting from chronic degenerative changes in the discs and facet joints. Isthmic spondylolisthesis may be congenital or traumatic and involves a fracture of the pedicles in the spine. Symptoms often begin in adolescence. Disc injury: There is an array of injuries to the disc. Herniation, protrusion, disruption, sequestration all refer to some type of disc damage. The term slipped disc is not accurate. The discs function to stabilize our spine. There are many actions which may damage the discs. The good news is that disc damage usually heels and the back and leg pain disappears. Although once you have damaged a disc, you will need to care for you spine and be mindful of how you move to help prevent future injuries. Scoliosis: This refers to abnormal side to side curves in your spine. Many people have minor asymmetry in their spine. Scoliosis usually begins at a very young age and is not reversible by exercise. Occasionally, this becomes a progressive problem and may be associated with other medical conditions. 13 OPTM Sports & Physical Therapy, Inc.

14 Low back pain and the importance of exercise Poor Posture and Body Mechanics: Try to minimize the amount of stress to your back. Avoid the perpetual cycle of irritating the tissue. Give your back a break from prolonged repetitive or sustained positions, especially positions of spinal flexion. Muscle Endurance and strength: Endurance and strength in your trunk and lower extremities are important. Your muscles support your body. Your ability to control your body over time is protective of your spine Motor Control: Refers to learning how to control the movement of your body. You can learn how to hold protective positions while you work to avoid irritating your symptoms. This takes concentrated effort and frequent practice. Every time you move is another chance to practice correct control. Train your brain in a good pattern of movement. Cardio-Vascular and Respiratory Fitness: Long term health is enhanced with the inclusion of cardio-vascular and respiratory fitness. This helps with the delivery of oxygen and other nutrients to your body. It is an important component of all aspects of your well being. What is good for your heart is good for your brain. Do whatever is necessary to stop smoking. Body weight: Maintaining a healthy body weight will do wonders for your general wellbeing and comfort. The healthier you are the more resilient you will be to any injury or illness. Flexibility: Tight muscles can predispose your spine to be in certain positions that place added stress to your spine and influence certain faulty movement patterns. Emotional status: How you perceive your life plays a major role in your recovery. Anxiety: It is common to be a little anxious. We will guide you through a safe and progressive recovery process. We are here to answer your questions and partner with you in your recovery. Depression: If you are depressed, movement and aerobic activity will be as effective as anti-depressant medication. Medication is helpful. We will encourage you every step of the way and guide you through your program. Fear: We can help you if you are afraid of injuring yourself. You will learn how to move safely starting with small actions and progressing to normal daily activities. This process is analogous to going to school. It is progressive and leads to your independence! You are your own best doctor! Our goal is to teach you how to manage your symptoms. You don t need to go to the dentist to have your teeth brushed, but you must brush them. If you can manage your symptoms, then you can treat yourself immediately and you will be aware how to keep yourself healthy. But, you must keep up with your health program. 14 OPTM Sports & Physical Therapy, Inc.

15 TRAINING THE TRANSVERSE ABDOMINALS AND PELVIC FLOOR MUSCLES These muscles strongly contribute to your mid section (core) control. They attach to your spine and support the abdominal contents. The transverse abs gives shape to your waist. They are the muscles you use when you pull in your waist. The pelvic floor muscles help control the flow of your bowel and bladder. Incontinence is common after childbirth or prostate surgery and may be the result of weak pelvic muscles. Core control refers to your ability to protect and limit motions of your trunk during activities of daily living. How well you can protect yourself depends upon the strength and coordination of the muscles between your knees and nipples. A. You should be able to isolate your spine moving on your pelvis, your spine and pelvis moving together on your hips and your hips moving on your pelvis a. Development of proper body mechanics, combined with learning how to control your core will protect you from injury. B. Exercise progression is dependent upon your position. a. Supine is the easiest b. Standing c. Sitting and squatting is the most difficult C. Technique a. Pull your navel toward your spine; pretend someone is measuring your waist. b. Contract your pelvic floor, as if you are stopping a flow of urine. This exercise is named a Kegel, after the doctor who developed it. i. Do not practice stopping the flow of urine as an exercise. This can change the function of your bladder or create problems. c. Learn to grade your contraction. Try to contract the muscles about 30% of the maximum amount possible. d. Incorporate this activity into functional movements, such as walking, bending over, squatting, and during all exercises. e. Use this and proper body mechanics in your daily living to protect yourself. 15 OPTM Sports & Physical Therapy, Inc.

16 ABDOMINAL BRACING The purpose of abdominal bracing is to stabilize your spine to protect it during activity. 1. Contract all of your abdominal muscles by tightening the muscles around your middle. Do not hold your breath. a. Place your hands on your belly to feel the muscles contract. Your belly should not be sucked inward or pushed outward. There should be no movement or change in the size of your belly. b. Try to grade the amount of your contraction. 100% may be the easiest, but you want to get to about 30% for most activities. The heavier the activity, the greater the activation of the muscles. 2. Next, bend forward from your hips. Your spine should remain straight and the pivot point should be at your hips. This is called a hip hinge. a. Your can bend as far forward as you would like as long as you maintain the abdominal bracing, your spine straight and the hip pivot point. b. Try this with squatting. c. Use this technique for lifting, pulling, pushing or any bending forward movement. 16 OPTM Sports & Physical Therapy, Inc.

17 The first step to getting better is to stop hurting yourself. 1. Identify and remove activities which aggravate your symptoms. 2. Develop trunk position awareness. Learn to differentiate between hip motion and lumbar motion. Maintain abdominal bracing. Groove movement patterns through practice. 3. Perform the appropriate exercises to improve the flexibility and strength of your trunk and hips. 4. Transfer your new skills to your daily life. The more frequently you use your skills, the easier it will become to perform your daily tasks. 5. Practice makes perfect. PROPER EXERCISE TECHNIQUE 1. Use abdominal bracing and move from your hips, keeping your spine relatively straight, to stabilize your trunk. Do not hold your breath to contract your abdominals. This is the essence of core control. 2. Move slowly to learn new motions and to ensure that you are performing the movement correctly. When you have mastered the movement, then you can increase the speed without sacrificing control. 3. Breathe in a relaxed manner. Do not hold your breath. This is not good for your blood pressure! 4. Incorporate the core control techniques into your daily life activities. If your control your core, then every movement you make is an exercise. The more you use this technique, the easier it will become to perform. Practice makes perfect. 5. Do as many repetitions as possible as long as all reps are performed correctly. Stop if you cannot control your movement. You risk injury by performing the movements incorrectly. 6. Perform your back exercises daily, even if only a few repetitions, for best results. Develop muscular endurance. This is accomplished by performing your exercises daily and to fatigue, or the loss of the ability to perform them correctly. 17 OPTM Sports & Physical Therapy, Inc.

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19 Homeostasis of the Musculoskeletal System 19 OPTM Sports & Physical Therapy, Inc.