BACK PAIN A PHYSIOTHERAPY GUIDE FOR PATIENTS WITH BACK PAIN

BACK PAIN A PHYSIOTHERAPY GUIDE FOR PATIENTS WITH BACK PAIN FRANK GILROY (Physiotherapist) TONY REECE (Back Specialist) HEATHER CAMERON (Student Physiotherapist) MOHAMED ADMANI (Student Physiotherapist) 1

Contents. The spine Pg 3 What is back pain Pg 4 Common causes of back pain Pg 5 Myths of back pain Pg 6 How to deal with an acute episode Pg 7 Why should you (stretch/cardio/core) Pg 8 Rehab phase 1 Pg 11 Rehab phase 2 Pg 16 Rehab phase 3 Pg 19 Rehab phase 4 Pg 21 Chronic rehab programme Pg 22 Tips to prevent recurrent back pain Pg 23 2

The spine. The spine is a strong and stable structure which allows the limbs to move freely and the body to bear weight, as well as protecting the spinal cord. It consists of vertebrae (bones), intervertebral discs, ligaments and muscles. Any of these structures could be affected and be the reason for your back pain. Intervertebral discs lie between the vertebrae to absorb shock during movement. Normally these discs are filled with fluid and movement helps to lubricate the joint, but due to lack of movement and the ageing process they become dehydrated and the space between the vertebrae narrows. This is often termed wear and tear and could be the reason for back pain however stiffness in the joints and muscles is a more common cause. 3

What is back pain? Back pain is a musculoskeletal disorder that is thought to affect 7 in 10 people in the UK throughout their life. It can be felt anywhere in the spine but is most common in the lower back area or lumbar spine. 98% of back pain is due to a simple sprain or strain and in most cases, there is no serious cause of back pain. It will usually resolve within three months with little or no treatment. Often, the exact cause of back pain remains unknown and is termed Non-specific low back pain. The cause is normally irrelevant; general exercise and movement as well as core muscle strengthening is usually the treatment of choice. Research has shown that this is effective in reducing pain in most cases. Once pain is reduced, maintaining an active lifestyle should help to prevent reoccurrence. In rare cases, there may be a more serious cause of back pain. If you experience any of these symptoms you should seek further advice: Loss of power in your legs Numbness or tingling in your genital/buttock area Loss of bladder or bowel control Difficulty passing urine Sudden, unexplained weight loss 4

Common causes of back pain. The incidence of people experiencing back pain is rising due to the increasing number of people in sedentary jobs and leading less active lifestyles. Common causes of back pain include: Poor posture Sitting for long periods of time Weak core muscles Being overweight/inactive Incorrect lifting technique 5

Myths of back pain. Movement will make my pain worse I should avoid exercise In most cases, movement will help to improve back pain. You should not be scared to move your back. Exercise is good for your back keeping fit and active should help improve pain and prevent it happening again. A scan will show what s wrong A scan often does not show what is wrong. It will even show signs of degeneration in people who do not have any pain. Hurt equals harm Recent research has shown that pain when moving your back does not mean it is causing damage. CSP (2016) 6

How to deal with an acute episode. If you are experiencing a flare up of back pain, it can be very debilitating and hard to know what is best to do. Following these simple steps should help to reduce your pain: Use an ice pack on your back for up to 15 minutes, 4 times per day Continue to move as much as your pain will allow Avoid bed rest You may find Non-steriodal anti-inflammatory drugs or NSAIDs helpful, like ibuprofen, but this should be discussed with your pharmacist Once your pain has started to settle, you can begin to follow the rehabilitation programme. 7

Why should you? Stretching. Stretching keeps your muscles from getting tight which allows you to maintain good posture. This, in turn, reduces the stress on your spine which could be the cause of low back pain. Stretching 2/3 times a day can help increase mobility, decrease pain and discomfort. If you have access to a pool, follow the stretching programme below. If you do not, that is not a problem as these movements can be done while lying on the floor. The pool provides a comfortable environment which allows the body to move non weight bearing. The goal of water therapy for low back patients is to build and maintain muscle strength and increase flexibility. When the core and low back muscles are strengthened, they are able to support the spine and ultimately improve everyday movements. Research has shown that water therapy has a range of health benefits such as increased spine mobility and pain reduction. Cardiovascular training. Cardiovascular training increases blood flow and nutrients to structures which enhances healing and can decrease tightness and stiffness in the muscles and joints that lead to back pain. Research has shown that exercise increases production of endorphins- body s natural pain killers which can help with back pain. Endorphins can also elevate mood and help you to stay active. 8

It is important to select cardiovascular exercises that are low impact so as not to injure the spine and to do them regularly so as to get the most out of them. Walking Walking is considered to be very gentle on the back and is associated with a low injury rate. Moreover, walking doesn t require any equipment other than a good pair of shoes and therefore can be done anywhere, inside or outside. Cross Trainer Cross trainer is another option for cardiovascular training. Due to the elliptical motion of the exercise, it is considered low impact and does not involve twisting or vigorous forward flexion similar to walking and therefore safe to use for patients with back pain. In summary, research has shown that moderate exercises play an important role in rehabilitation of back pain. Core Training. The Core is made up of a group of muscles; Transverse Abdominis, Rectus Abdominis, External Abdominal Oblique and Internal Abdominal Oblique which can be seen in the diagram below. These core muscles are vital in helping to keep the body balanced and stable and to minimise the load put through other joints. 9

The next part of this program shows you different phases of rehabilitation for your back pain. NOTE: This programme has been divided into 2 categories, Acute and Chronic. The Acute rehab programme should be followed if you have had a recent episode of back pain while the Chronic rehab programme should be followed if you have had a history of back pain. Stop these exercises immediately if you feel pain or discomfort in your back and let your physiotherapist know If you are performing these exercises for the first time, make sure the therapist is there to guide you through them. 10

Acute Rehab Programme. Phase 1. Start with walking and progress to running if able (not swimming) in the pool for between 2 and 4 laps followed by exercises 1, 2 and 3. Repeat this fours times. If you have no access to a pool, you can replace running with walking on land and complete the exercises whilst lying down. It is important to stop these exercises if your pain levels increase. Remember to wear a floatation belt before you go in the pool. Exercise 1: While holding on to the wall, push your chest away from the pool. Remember to keep your head straight so as to avoid neck pain. You should feel this stretch in your abdominal muscles. Repeat 10 times. 11

Exercise 2: While holding on to the wall, bring your knees to your chest. You should feel this stretch on your lower back. Repeat 10 times. Exercise 3: While holding on to the wall, move your legs in a circular motion. The movement should be as big as your pain will allow. This exercise will be stretching the muscles found at the side of your body. Complete 10 circles in one direction and then 10 in the opposite direction. 12

Phase 2. Continue to do pool exercises whilst progressing onto phase 2. If you are performing these exercises for the first time, make sure the therapist is there to guide you through them. If you feel any pain or discomfort in your back, stop doing these exercises immediately and let your physiotherapist know. Use the cross trainer for 15 minutes, beginning at a low resistance and progress to a higher resistance as able. 13

Stretch 1: While lying down, bend one knee while bringing the other knee to your chest, supporting with your arms. Remember to keep your hips on the floor. Hold for 30 secs then repeat on the other side. Repeat 2-3 times per day. Stretch 2: While standing, lift your right arm over your head towards the opposite shoulder. You should feel the stretch on the right side. Repeat the stretch using the left arm over the head towards the opposite shoulder and you will feel the stretch on the left side. Hold each stretch for 30 secs, 2-3 times per day. 14

Stretch 3: Knee rolls: while lying on the floor, bend your knees and roll them to each side. Hold each position for 20/30 seconds. You should feel the stretch on the sides. Repeat 2-3 times per day. Stretch 4: While on your hands and knees, arch your back like in image 1. Hold this position for 30 seconds. Then relax down into the position in image 2. Hold this position for 30 seconds. Repeat 2 to 3 times per day. Image 1. Image 2. 15

Core exercises. Once you can hold each exercise comfortably for more than a minute move onto the next phase. 1. Bridge Initial position: Lie on your back with your knees bent Flatten the top half of your back into the ground and lift your hips up by pushing through your heels Focus on keeping a straight alignment 16

2. Plank Initial position: Start on your knees and forearms Straighten out your legs to take the weight through forearms and feet. Focus on tightening your core muscles to keep your back straight 3. Side Plank Start side lying with legs straight Place your elbow directly under your shoulder to prop up your torso Focus on keeping your body in a straight alignment 17

Phase 3. You may continue with phase 1 and phase 2 exercises as you progress onto phase 3. Stop these exercises immediately if you feel pain or discomfort in your back and let your physiotherapist know. Complete these exercises 2 times per day, 5 days a week Once you can hold each exercise comfortably for more than a minute move onto the next phase 1. One leg plank Begin a normal plank Lift one leg straight in a controlled movement and hold it 18

2. One legged side plank Begin a normal side plank Lift your top leg up in a controlled movement and hold it 3. One legged Bridging While keeping one leg straight perform a bridge Focus on keeping your hips level with each other 19

Phase 4. Stop these exercises as soon as feel any pain or discomfort in your back and let your physiotherapist know. 2 times per day 5 days a week Once you can hold each exercise comfortably for more than a minute move onto the next phase 1. One leg plank with band Attach a theraband to something stable and wrap it around your thighs Perform a single leg plank 20

2. One leg side plank with band Wrap a theraband around your ankles Perform a single leg side plank 3. One leg bridge with band Attach a theraband to something stable and wrap it around your thigh which is planted Perform a single leg bridge 21

Chronic Rehab programme. If you have long standing back pain (i.e longer than 6 months), you should also do the exercises shown in rehab phases 1, 2, 3 and 4 with further progressions. Stop these exercises as soon as feel any pain or discomfort in your back and let your physiotherapist know. Phase 1 o Increase speed of running in the pool or use a cross trainer instead of walking. o Increase the number of repetitions of exercises in the pool as pain allows. Phase 2 o Increase time on cross trainer and progress to higher resistance as pain allows. o With stretches, hold each position for 3 seconds and repeat 10 times Phase 3 and 4 o Progress onto next phase once you are able to hold the position for over 1 minute For future o You may attend a yoga or Pilates class to help with core strengthening. o In order to prevent future episodes of back pain, you should continue to do exercises in this programme as well as any other activities that you enjoy. 22

In conclusion, the NICE guidelines (2016) suggest that activities such as stretching, strengthening, aerobic exercises are highly recommended for all patients with low back pain. Tips to prevent recurrent episodes of back pain (NHS.UK, 2017) 1) Do regular core exercises and stretches 2) Stay active doing regular exercise can help keep your back strong; adults are advised to do 150 minutes of exercise a week. 3) Avoid sitting for too long when driving or at work. Keep a timer that will remind you to get up and move around every 30 minutes. 4) Bend your knees when lifting things. 5) Maintain a good posture and sit up right when sitting, using computers and watching television. Do not sit in a slouched position as that increases the tension in the muscles. 6) Lose weight through a combination of a healthy diet and regular exercise as being overweight can increase your risk of developing back pain. 23

References McIlveen, B. and Robertson, V. (1998). A Randomised Controlled Study of the Outcome of Hydrotherapy for Subjects with Low Back or Back and Leg Pain. Physiotherapy, 84(1), pp.17-26. Gordon, R. and Bloxham, S. (2016). A Systematic Review of the Effects of Exercise and Physical Activity on Non-Specific Chronic Low Back Pain. Healthcare, 4(2), p.22. Ullrich P.F. Low Impact Aerobic Exercise. [(accessed on 15 November 2014)]. Available online:http://www.spine-health.com/wellness/exercise/low-impact-aerobic-exercise. Krismer, M. and van Tulder, M. (2007). Low back pain (non-specific). Best Practice & Research Clinical Rheumatology, 21(1), pp.77-91. Kumar, S. (2011). Efficacy of segmental stabilization exercise for lumbar segmental instability in patients with mechanical low back pain: A randomized placebo controlled crossover study. North American Journal of Medical Sciences, pp.456-461. BERNSTEIN, I., MALIK, Q., CARVILLE, S. AND WARD, S. (2017). LOW BACK PAIN AND SCIATICA: SUMMARY OF NICE GUIDANCE. BMJ, P.I6748. Nhs.uk. (2017). Top 10 back care tips - Live Well - NHS Choices. [online] Available at: http://www.nhs.uk/livewell/backpain/pages/topbacktips.aspx [Accessed 1 Aug. 2017]. Gilroy, F. 2017. Frank Gilroy Physiotherapy. Available from: http://frankgilroyphysiotherapy.co.uk/ [Accessed 2 Aug. 2017]. Visit us at http://frankgilroyphysiotherapy.co.uk/ for more information. 24