UNDERSTANDING CHRONIC BACK PAIN

BE IN CONTROL OF YOUR BACK

Copyright © E. Franklin Livingstone, M.D.

It is important to remember that no matter what you are doing, your back is always at work to some extent, whether standing, sitting, lying, lifting, or seemingly doing nothing. The back is always there supporting your upper body and it never rests completely. This is one of the reasons why back problems are so common and are not infrequently chronic, and that is why, they do not go away. If you sprain an ankle or have some other joint or bone injury, the affected area will be splinted or casted to take it out of action. We simply cannot do that effectively with your lower back, and therefore, if you do injure it, it must function in spite of this.

Before you had your back problem, if you're like most people, your back was relatively healthy, and nearly totally taken for granted. In fact, our backs function very well until they are injured, but not infrequently do not heal up rapidly or completely. Remember that when your back is injured, it is more easily reinjured and will not tolerate even normal stresses and strains of activities of normal living. Now, with a bad back, the posture that may have been well tolerated before the injury is not tolerated at all and now every aspect of activity must be considered relative to its relationship with your back and whether or not it will have a negative effect..
It may never have been important to you before just how strong or healthy your back was. However, after injury, it must become a priority if you are to gain control over your back problems so that it will gradually heal up, giving you less discomfort and impairment.

In most cases, chronic back problems relate to cycles of overuse, reinjury, or abuse to the back and most all of this relates to behavioral patterns that you have developed over the years, and perhaps, to some extent in relation to the back problems that you are having. You must learn how to use your back correctly, how to stand, how to sit, how to lie, how to lift, how to bend, how to twist and turn in ways that do not recurrently aggravate your back even if to only a slight degree, because these aggravations simply add to one another to keep your back from getting completely better.

Nearly 100 million Americans, at one time or another, suffer from some form of chronic pain. A large percentage of these problems relate to low back pain. Regardless of where the pain is, there are often many characteristics that will be similar and if you are to gain control over your problems, then you will need to learn everything you can about pain and how it relates to your body and your mind. It is only from a position of knowledge that you can hope to gain control over this problem of chronic pain, to overcome it.

A positive approach to pain does not mean that you always think of it in nice and positive terms. It means that you go out of your way to learn everything you can about it so that you are in the best position of being able to control it, and to minimize the negative impact that it may have in your life. A positive approach to chronic pain means that when the pain occurs or worsens that you immediately take proactive measures to effectively treat the aggravation of the symptoms and also to define what has caused the aggravation of symptoms so that you may eventually deal with that particular factor so that it does not continually reaggravate the problem and prevent eventual healing and resolution.

You cannot change the fact that your back has been injured or is weak and unhealthy. You can, however, rehabilitate your back by stopping the various cycles of abuse and reinjury and by developing appropriate knowledge and exercise regimes to correct the muscular deficiencies as well as any other ongoing perpetuating issues such as poor posture or poor body mechanics.

You and only you can rehabilitate your back. First you must learn everything you can about the anatomy of your back and how it functions, how you can strengthen it, how you can develop proper movement techniques (body mechanics) and how you can function throughout your day while protecting your back from reinjury, overuse or other cause for aggravation. Learning the proper ways of utilizing your back while developing a thorough and effective exercise rehabilitation program are two of the most important keys toward regaining normal back function and controlling its impact on you.

The vertebral column has a very difficult job, it must support the trunk, upper extremities and head while allowing for complicated movement in several directions. It is a very powerful musculoskeletal arrangement, however, it does have its weak points, namely the neck and lower back. It needs proper care and attentiveness and good health if it is to function without problems, but after injury it particularly needs priority attention if it is to be improved. You will need to know how your back functions, the location and function of its' muscles, as well as the complicated relationships of the bones and ligaments of the vertebral column, the vertebrae and their interrelationships. You cannot treat your back problems effectively without understanding it.

In the healthy spine, there are three curvatures that are important. These curvatures are maintained by the shapes of the vertebrae (24 bones of the spinal column), and in the normal spine these curvatures are graceful and represent the inward curvatures at the neck and low back (lordosis) and the outward curvature of the posterior chest or thorax (kyphosis). None of these curvatures should be exaggerated, nor should they be straightened out, or reversed. The muscles attaching to your spine aid in back support as do the ligaments which are fibrous tissues similar to tendons that hold the vertebra together. Laxity in the ligaments cause more strain on the muscles and weakness in the muscles causes more strain on the ligaments. All of these structures work together in the normal healthy spine and when one is affected the other is always affected as well.

The intervertebral discs are made of cartilage, gelatinous and fibrous tissue and help allow for movement in the normal spine, while at the same time acting as shock absorbers. Normally, they are elastic and flexible but tend to dry out and become hard and less flexible with age and because of this are more easily damaged. If not dried out, the discs are flexible and can change shape and this is important in allowing normal spinal movement, but as they dry out and get firm they are no longer able to accommodate as well to changes in the spinal alignment and can create problems.

Years of abuse are cumulative and there is often progressive back deterioration, discomfort and impairment. Injuries to the disc become more common as we age and as they become dried out, more brittle and less flexible. Ligaments can also change with age and become more easily injured. As ligaments begin to wear, tear and stretch, muscles must provide more stabilization of the spine, and they, too, suffer from rather constant abuse giving us more problems, more weakness, discomfort and impairment and more muscular deterioration.

Understanding proper body alignment is an important part of the knowledge required in order for you to control your back problems so that it will gradually improve. Maintaining the appropriate curvatures of the spine during activities and at all times is very important in developing good movement techniques that protect your spine from undue or unusual stresses that may cause injury or aggravation.

In developing your back rehabilitation program, it is important to remember the natural alignment and curvatures of the back. The muscles of the thighs, buttocks, and abdomen must be strengthened to provide better protection of the back, particularly during lifting activities. These muscles are much larger and stronger than the muscles in your back and have better mechanical advantage so that they are protective when used properly during activities. The development of strength in these muscles while developing good movement techniques (body mechanics) are two very important aspects of your rehabilitation program. Both should improve with regular and frequent exercise and practice.

An important aspect of your physical rehabilitation program will be a stretching program. Your joints must be flexible, that is, they must be able to move through a normal range of motion without restriction. You must be sure that all your joints have good function; regular participation in a thorough exercise and stretching program will assure this.

Your awareness of body mechanics and especially your diligent effort at maintaining back alignment and natural curvature during your activities will go a long way in preventing further reinjury aggravation of your back problems. You must manage your activities with safe body mechanics whenever your are, at work, at home or at play. You must be committed toward practicing safe techniques of body mechanics so that you develop good patterns of these movements. You must plan your activities ahead of time, making sure that you are using your back to maximum advantage while not putting it at greater risk for reinjury or aggravation due to poor body mechanics. Remember, you may well be more at risk when you play than either at work or at home. It doesn't matter how or where you hurt yourself, the result is the same; greater discomfort and impairment.

If your back is out of alignment, and the natural curvatures are changed, it becomes more likely to be injured and is at great mechanical disadvantage during many activities. Remember, we are using our spine all day long and all night long. It is no wonder that we have so much trouble with this area of our body. It is, in fact, one of the weaker points of our anatomy, it joins our upper body to our pelvis and lower body and there is a great deal of force transmitted through this connection. Poor body mechanics, poor posture and deconditioning, very frequent in our society, in the case of low back problems, will often not allow healing and resolution.

Disc injury is more likely to happen in the forward flexed spine (bending forward), and is more likely to occur with twisting maneuvers at the same time. You must remember to maintain your alignment and curvatures keeping your back "straight" and using your hips and legs for lifting maneuvers. Keeping the load that you are lifting as close to the body as possible, lowers the stresses across the lower back and reduces the likelihood of injury as well.

Bad posture can prevent chronic back problems from resolving. Many of us have bad posture and it is important to become aware of it. Posture is something that can be changed, it is behavioral, and your increased awareness is your only hope of being able to do something positive about this. When you sit without support, if you slouch you reverse the normal curvature in the lower back, putting your back at risk for disc injury, as well stressing all of the muscles and ligaments in the posterior aspect of the spine at the same time. If this goes uncorrected, it can cause progressive increases in your back problems and can be a significant factor in permanent deterioration of the vertebra, ligaments, discs and other structures involved. Bad posture simply cannot be left unchanged if back problems are to resolve.

In chronic back pain a number of things occur. Muscles become weak, and normal curvatures and alignments are not maintained. Abdominal muscles weaken due to lack of activity or exercise, while at the same time weight increases. The stresses on the spine are increased because of the reduced support given by the deconditioned back and abdominal muscles and by the weight of the abdominal region and abdominal contents which pull upon the back. You might not think so, but the abdominal muscles are very important in supporting the spine and your exercise rehabilitation program should include both back and abdominal muscle strengthening. All of your exercises should be prescribed by your physical therapist or doctor. (Please reread the preceding sentence.)
The vast majority of chronic low back problems do not relate to bone or disc injuries, but to muscle and ligament injury. This is one of the reasons why your best hope for rehabilitation of your back lies in exercise rehabilitation. You must, however, understand the details of your back problems so that your exercise program will help you and not hurt you. It needs to facilitate your improvement and not aggravate your ongoing difficulties.

Body mechanics is the way in which you use your back, your movement patterns. If you are using good body mechanics, you are maintaining good spinal alignment and curvature, and you are protecting your back during activities, preventing reinjury and also aiding in improving strength and flexibility. Posture and lifting are both important aspects of body mechanics relative to protecting your spine and you must learn as much as you can about both of these functions. When lifting, you much maintain appropriate alignment and curvature by using primarily your lower extremities to provide the power required. Remember that your legs are much stronger than your back, and that they can provide much greater force. You should squat, bending at the knees and the hips, but not at the waist, getting as close to the load as possible and thus eliminating as much strain as possible. Your hips, buttocks and leg muscles will do the lifting for you and protect your back if you allow them to. You may have to bend forward a bit at the hips if the object you are lifting or moving is too large to get close to. Again, you must be careful to maintain proper spinal alignment and curvature, and as with any lift, avoid twisting while lifting. You may turn on your feet while lifting, however, do not twist your spine while lifting. Remember to tighten your abdominal muscles prior to lifting, and again, as always, use your leg and buttock muscles primarily.

It is important that you plan lifting activities and that they should always be done twice, first in your mind and then with your body. An old adage "engage your mind before putting your body in gear" is very important for developing good body mechanics, lifting and postural habits.

When objects to lift require that more than one person participate, one of the participants should be designated as leader. The lift should be planned in advance and everyone on the team should know the plan and timing so that everyone is working together. When possible and especially for heavy or awkward lifting, mechanical help, such as mechanical lift or other aid should be employed. Remember that you are better able to push than you are to pull.

The best support for your back is good posture. When standing, in the healthy spine, the shape of the vertebrae, and the ligaments that connect them provide most of the balance support but require some additional help from the muscles of the back, the buttocks and the abdomen.

In the normal back, normal alignment and curvature are easily maintained for long periods of time without undue fatigue. However, in the unhealthy spine relationships are changed and normal posture requires more effort and may not be tolerated for nearly so long.

Your back needs support even while you are sleeping and this may be easiest accomplished using a firm mattress and while sleeping on your side with hips and knees bent a little. Sleeping supine, that is, on your back, may be more easily tolerated if you put a pillow under your knees, relieving some of the stress on your lower back. A mattress that is to soft or non-supportive may cause prolonged poor posture and may well aggravate back strain.

Sitting properly is an extremely important aspect of controlling your ongoing back problems. In our society, we spend a great deal of our time sitting, yet most seats or furniture are not well designed to provide good low back support and special attention to sitting posture is necessary. It is quite clear that sitting is often much harder on a low back than standing. When standing many of our trunk muscles are active and help to provide support for the back, while sitting many of these muscular groups are relaxed so that the back is even less supported. If you spend a good deal of your time sitting, as for example during your working hours, you may well note that backache and back fatigue progress as your work week rolls on. By the end of the week you may note having more problems than you had at the beginning of the week. This can be a recurrent cycle and may well result from prolonged poor posture and its cumulative toll on the lower back. The largest percentage of back aches are caused by long periods of prolonged sitting in one position and especially with a "slouching" posture. Remember, that posture is important in all chronic back problems. Your back problem may not resolve until the postural problems are corrected.

Good sitting posture can only be attained actively, that is, we cannot establish good posture while seat cushions and pillow supports alone, your back muscles and abdominal muscles must participate.

With slouching, normal curvatures are changed to the point that your muscles can no longer support the posture, the ligaments are required to do more work than they are designed to do. The ligaments are put under prolonged stretch which can cause lengthening as well as the development of stiffness, fatigue and backache. With alterations in ligament length, there may be more instability in your back and further likelihood of damage to ligaments, muscles, discs, bones or nerves.

You simply must correct and prevent poor posture in all activities. You must pay particular attention when sitting. At first you may have to exaggerate good sitting posture, but you should not sit for prolonged periods of time without shifting your weight and position a bit. Every 10 to 20 minutes stand up, change your position entirely, stretch out your back, walk around a few steps and sit down again while maintaining good posture. You should also learn and develop safe techniques for bending and reaching while sitting, maintaining proper back alignment and curvature. Moving your chair as close as possible to your work to prevent undue or excessive stresses across your upper and lower back is helpful.

There are a number of helpful hints regarding sitting properly and with appropriate support. It does not matter what sort of chair you use, most chairs can accommodate good sitting posture though they may not facilitate it. Only you can assure good sitting posture. Slouching can be largely prevented by moving your chair forward as far as possible so that you are comfortably close to your work. Support at the lumbar area can be very helpful and can be made y rolling a towel, newspaper or some magazines and positioning them in the small of the back. This will provide support while at the same time providing you with more awareness of your lower back posture. Sometimes, a wedge cushion can help maintain your lumbar curvature (lordosis) and may often be valuable when used in conjunction with a lumbar support.

When reading at your desk, hold the materials up and closer to your face as opposed to bending over your desk for prolonged periods while reading. You should try to find the most comfortable position that allows you the most tolerance during your sitting activities. Sudden movements should be avoided and a periodic stretching is very important toward maintaining healthy flexible muscles and ligaments. Periodic performance of simple back exercises, careful management of turning and bending activities while sitting can prevent undue stress and stain and can prevent unnecessary aggravation of your back problems due to sitting activities. There are a number of simple exercises that can be done at your desk and many while sitting that can prevent undue stress and strain and can prevent unnecessary aggravation of your back problems due to sitting activities. There are a number of simple exercises that can be done at your desk and many while sitting that can prevent the development of stiffness and backache, increase your tolerance while improving your posture and movement patterns. These exercises will be designed to treat various parts of your back, neck or thorax and will also involve abdominal and upper extremity strengthening.

A simple regimen that can be done in your chair or at your desk will include simple neck range of motion exercise and isometric neck strengthening. Attention to neck posture can prevent undue fatigue. This is accomplished by holding your head up with your chin in. Exaggeration of this position is held for several seconds, and repeated 5 to 10 times and should be done every 20 minutes, or so, while awake.

Periodically standing up placing your hands on your hips and gently stretching yourself backwards, as if bending your back backwards, releases a great deal of muscle tension and can reduce or prevent the development of lower back stiffness. Hold the position of a gentle backward bend, for two or three seconds, then release and you should repeat this 5 to 10 times frequently during the day, and at 20 to 30 minute intervals.
The middle part of your back, the thoracic portion, is stretched and exercised by lifting your arms above our head and gradually stretching them backwards and also by putting you elbows behind your back and trying to touch them to each other, followed by a "self-hugging " motion. Again, this should be done 5 to 10 times and repeated several times during the day at 20 to 30 minute intervals.

Abdominal muscles can also be strengthened in a sitting position by sitting upright, exhaling and tightening your abdominal muscles and holding this as firmly as possible for a count of between 5 and 10. This should be done in sets of 5 to 10 repetitions as with other exercises, gradually increasing as strength and tolerance allow, it should be done at frequent intervals so that gradual strengthening and tightening of the abdominal muscles occur.

The above group of exercises can be accomplished in three to four minutes and some can even be accomplished while doing other work. It is important that you establish a good habit of performing these exercises very frequently and at regular intervals. Developing these into a habit pattern will best assure that your prolonged periods of sitting posture do not continually, and on a daily basis, aggravate your low back problem and prevent ongoing healing and resolution.
The following is a series of exercises that are common to most exercise rehabilitation programs for chronic low back problems. Your program should be developed by you with the advice of your physical therapist. You must learn the techniques appropriately, following through with frequent exercise participation. Exercise in six sessions per day, limiting duration and intensity according to your tolerance, but not sacrificing frequency. You must be sure that you are doing your exercises appropriately and that your exercise program is not causing ongoing aggravation of your back problems.

Partial sit-ups:

A partial sit-up exercise is important toward redevelopment of abdominal muscular strength and tone. It you have a "pot belly", this is aggravating your low back problems and must be corrected by weight loss and muscular strengthening and toning. A partial sit-up is done with you lying supine, that is, on your back, on a firm surface such as the floor with your knees bent. You raise your head, shoulders and upper back off of the floor and hold for 3 seconds without straining your neck and without coming up into a sitting position. Gradually increase the intensity and the number of repetitions of this exercise. Don't hold your breath while doing your exercises.

Knee to chest:

The knee to a chest maneuver is important in developing flexibility in the back, particularly in flexion. Lying supine, slowly pull one knee at a time up toward the chest. Hold for a few seconds and release gradually, always making your movements slow and gradual and not jerky and rapid. Do this to one side and then the other side and then do it both sides at the same time, pulling both knees up to the chest. Do 5 repetitions of each leg, alternating, then 5 repetitions doing both legs at once. Gradually increase the number of repetitions.

The pelvic tilt:

The pelvic tilt is an important maneuver to help you develop better posture and better postural awareness. Standing with your back against the wall, tilt your pelvis so that your lower back rests flat against the wall, hold for a few seconds and then tilt your pelvis forward so that there is space between the wall and your lower back and hold this for a few seconds. Repeat this and gradually increase the duration and intensity and repetitions of this maneuver as your back tolerates it. You may also do this lying down with your back on the floor, but never on a soft surface.

The wall slide:

Another exercise to do while standing up against the wall is known as "a wall slide". With your back against the wall and your feet slightly away from the wall, slide into a partial sitting position and hold for a few seconds and then stand up sliding up the wall. Increase your participation in this activity both in terms of the duration and intensity and in terms of repetitions as you can tolerate, but do not push so fast as to cause aggravation.

For the next two exercises, assume a position on your hands and knees. While in this position, round your back arching it upwards like a cat, hold for a few seconds and then arch your back downward lifting your head back at the same time and causing your back to "hollow" like a sway back horse. Hold this position for a few seconds and then reverse it. Approach this activity cautiously as you would approach any new exercise activity. This is a variation of the "Pelvic Tilt".

While on your hands and knees, also do diagonal reaching activity by lifting one leg backward and upward while lifting the opposite arm forward and upward as well. Hold the position for a few seconds and repeat lifting the opposite leg and arm. This will gradually help to strengthen muscles of your back, as well as abdomen and buttocks while increasing your flexibility at the same time.

Push-ups:

Now assume a prone position, that is, lying down on your stomach. In this position, you will be extending your back, by stretching it backwards and doing a modified push-up. The pelvis should remain on the floor and your hands should be in front of you pushing your shoulders and upper body upward so as to bend your back backward. You should not do this to the point of significant pain. You should approach this exercise very gradually, increasing only a little bit at a time, as you tolerate easily.

Bridging:

Turn over so that you are lying on your back now with your knees elevated a bit, that is, bent a bit at the hips and knees. You will now try to push your feet into the ground or into the surface upon which you are lying, while lifting your buttocks up off of the surface. This will cause a tightening of your buttocks muscles and a gradual strengthening. You should hold this "bridged" position for several seconds and repeat five to ten times initially, gradually increasing as your tolerance allows.

As you become stronger and able to tolerate more activity, you should be developing more of a priority toward general fitness. Aerobic exercise must be one of your goals and you should pursue it as tolerated, and incrementally so you will gradually redevelop better general fitness. More and more this will result in a preventive program allowing you improved strength, endurance and activity tolerance with less and less likelihood of reinjury or aggravation.

Aerobic exercise is exercise that does not exhaust you or cause significant shortness of breath, but does stress your musculoskeletal system as well as your cardiovascular systems and results in improved fitness. In aerobic exercise you will exercise until your heart rate reaches a specific rate known as your "target heart rate". It is recommended that you consult your doctor regarding your target heart rate and that you learn to monitor your heart rate appropriately so that you do not over do your aerobic exercise. Performed properly, aerobic exercise not only causes a gradual improvement in general fitness and shape, it also increases circulation as it strengthens your heart and respiratory systems. It improves your sense of well- being by improving your physical fitness, relieving stress, causing greater relaxation and also causing a release of endorphins which are your bodies own natural pain killers.
There are a number of ways that you can pursue aerobic exercise. You should try to have fun at it, but you should not carry it to the point of fatigue, exhaustion or aggravation of your back problems. As with any exercise modality, you should start very slowly and cautiously, gradually increment your participation, both in terms of duration and intensity. Getting a friend or your spouse to participate with you can be very helpful and add to the fun of aerobic exercise. Vigorous walking or light jogging, swimming, cycling or low impact aerobics are often utilized and can be very beneficial if approached with due caution. Restoring a high level of general fitness is imperative if you are to gain maximum control and resolution of your back problems.

There are other aspects to your ongoing back problems that you must be aware of and deal with. Both inactivity and stress cause ongoing aggravation and may cause deterioration in your back condition. Inactivity is best dealt with in an appropriate exercise and activity program, but stress must be understood and dealt with often in different ways. However, exercise and activity are both very important methods toward stress relief and greater relaxation.

Most persons with significant back problems can easily relate to the fact that inactivity causes progressive stiffness and aching. But, how does stress relate to your back? Most persons with chronic back problems can relate to the fact that when they are under a great deal of stress, or if they are anxious, frustrated, angry or upset, their back problems tend to escalate. They may not know exactly how stress affects their back discomfort, but they can easily understand that the higher the level of stress, the higher the level of discomfort experienced. There is probably not a simple explanation for this, and it probably involves processes at the muscular level as well as at the central nervous system level. (The central nervous system is the brain and spinal cord.)

The fact that we have pain over an extended period of time causes us to become rather sensitive to pain rather than more tolerant of it, as one might expect. You must come to realize how important your mind is in controlling your pain. This is not to say that your pain is in your head, quite the contrary, however, it is your brain that interprets the signals as pain and causes the suffering that you experience. Furthermore, your brain has the potential for either increasing or decreasing the extent to which you experience the pain and suffering.

All of us are stressed every day, and often many times each day. In fact, throughout our lives we are continually bombarded with stressful stimuli of one sort or another. But how often are we stimulated to relax? Over the years, we can, in fact, lose some of our ability to relax, and moreover, we lose the objectivity of knowing when we are truly relaxed and when we are not. Part of learning to control a chronic pain syndrome is getting in touch with the body again, regaining more control over it. There are a number of ways of redeveloping an effective relaxation response and becoming more attuned to the body. All of these techniques, however require effort on your part, to learn the techniques and to practice them so much that they become habitual in your everyday life.

Biofeedback is a technique for improving your awareness of your body. It takes a certain aspect of your body functioning and amplifies it so that you are aware of it by auditory feedback (sound) or visual feedback. For example, the state of muscle relaxation can be determined by EMG (Electromyography = Electrical activity in muscles), in which surface electrodes are placed on the skin and measure the electrical activity of muscles. If a muscle is totally relaxed there is no electrical activity and if there is electrical activity we can either see this on a dial or hear it on a speaker that gives us a variable signal depending upon the level of muscle , or activity. Using this feedback, we can become more capable of reducing this muscular tension and restoring a normal relaxation response, that is, complete muscular relaxation, no electrical activity. There are many other forms of biofeedback, including skin temperature and skin electrical resistance as well as others. The polygraph test, the "lie detector," is an example of the use of multiple modes of biofeedback to detect stress levels when persons are not telling the truth.

There are a number of relaxation techniques which can be very helpful when used separately or in conjunction with biofeedback. These may include breathing techniques, or progressive muscular relaxation.

Visualization techniques are another way of focusing attention away from pain and allowing more complete relaxation. Meditation has a similar effect and can often be very effective There are, of course, many different forms of meditation techniques that one can pursue.

Many of us have a very negative approach to our pain, focusing only on the discomfort. Taking a positive approach, using self-talk of a positive nature, one can learn to improve one's focus, be more productive and effective in controlling back problems. Use positive affirmations such as "I am gaining control of my back problem", My back is feeling better", and "If my back starts bothering me I'll take care of it immediately and effectively, as I've been taught in my rehabilitation program". Positive self-talk can change one's "mind set", but one must be very persistent with these sorts of activities.

Occasionally, counseling is necessary related to psychological conflicts or emotional distress issues, and may require more thorough and objective intellectualization and treatment. Support groups can also be very helpful in the development of a positive approach to chronic pain management and in redeveloping socialization skills and a more open attitude toward the ongoing problems.

One of the underlying premises of back rehabilitation is that you cannot continue to reaggravate or reinjure your back and expect it to get better. The muscles and ligaments are unhealthy, therefore they are easily injured and even small injuries will add up, one upon another, and prevent healing and resolution of your back problems. You must find positions that are comfortable to you, whether standing, lying or sitting, and movements likewise that do not aggravate you. Once these positions and movement patterns are identified, they must be maintained and developed into habits so that more and more you are spending your time in non-aggravating positions and activities and thus allowing muscle healing to occur. You should vary your pelvic alignment and position by using your abdominal and buttock muscles and try to sustain your position of comfort.


UNDERSTANDING EXERCISE IN CHRONIC BACK PAIN

One of the most important premises in back rehabilitation, is that both over-activity and under-activity can be detrimental and aggravating to your pain syndrome. The old cliché'"no pain no gain" is totally inappropriate and not consistent with progressive healing in musculoskeletal back conditions. Normal muscles can withstand a good deal of use and abuse, but unhealthy damaged muscle tissue is extremely easy to reinjure. Even though minor, all reinjuries are cumulative and tend to impede or halt the healing process.

With this in mind then, it becomes important for the patient to remain pain free, managing all daily activities within the limits of tolerance, including the rehabilitation exercise program which should be pursued in frequent short bouts. You must learn ways of accomplishing exercise and activity without aggravating your back. This may not always be easy, it may require some creativity and it always requires a great deal of effort.

When you are exercising, it is important that you maintain positions of relative comfort, avoiding those activities and positions which are aggravating. Another underlying concept of back rehabilitation is to avoid or prevent all aggravations, knowing that they represent minor injuries that accumulate and prevent overall healing and progressive strengthening.

What exercises are used is not as important as how they are approached. Any exercise or activity that can be done with impunity, that is, without aggravation of your back condition, can be pursued. Performing activities, however, must always be done in a graded and incremental fashion, starting gradually and maintaining your level of performance of exercise or activity within your upper and lower limits of exercise tolerance. This must be accomplished every day, and must be given a high priority and a great deal of presence of mind. Incremental exercises such as; partial sit-ups, bridging, pelvic tilts, push-ups, back extension strengthening and progressive resistance exercises as well as isometric exercises can all be very beneficial if approached in a technically appropriate manner with the right frequency and intensity. The use of aerobic exercises, such as the treadmill or stationary bicycle, can be very important for general fitness and aerobic conditioning, but can never replace an appropriate, well designed back and abdominal strengthening and stretching program.

The back education classes that you will attend are extremely important. If they seem somewhat boring, adjust your attitude because the information that is presented is important for you to know in its entirety and in detail. It must be stressed that your success at gaining control over these problems will be proportional to your effort in developing a thorough understanding of all aspects of these problems.

The instruction in body mechanics is extremely important and it is essential that you practice it with significant frequency, so as to develop appropriate motor patterns when using the back in activity or exercise. Correct body mechanics are extremely important and incorrect body mechanics are often part of the reason why back pain has developed and continued. Even if not a cause of your back problems, body mechanics change as a result of pack pain and often become dysfunctional. While these altered movement and guarding patterns may be meant for protection initially, over the long run, these abnormal patterns tend to aggravate back problems and facilitate their persistence.

As with exercises, in all activities, the patient must maintain a pain free status, as much as possible. If you are recurrently injuring your back, even if only very minor injuries, they will be cumulative. , adding upon one another until there is significant injury and marked aggravation. Your must spend time evaluating your activities and behaviors. How do you sit at home? How do you sit in the automobile? How do you manage your movements? When you get up are you impulsive? Do you move in a jerky fashion, or are you careful in your movements? These are important aspects in the persistence of musculoskeletal back pain and must be evaluated. If no one else evaluates them, you must evaluate them yourself. You must be in charge of your back rehabilitation program, if it's going to be successful. You must master the information related to all aspects of your problems, and manage your activities and behaviors from day to day to prevent reaggravations.

Starting an exercise program is often accompanied by increased pain and impairment. This is generally because of the fact that you are putting to use weak muscles inactivities to which you are unaccustomed. Stretching before and after exercise is necessary to restore optimal muscle length while accomplishing strengthening and may cause some additional discomfort. Remember not to push yourself too fast at first, as is often the temptation.

One very important aspect of your control over this musculoskeletal pain problem is how you react to aggravations of your pain or impairment. Do you focus on the pain, the misery, and the impairment, or do you try to figure out why your having the aggravation. There is always a reason for the aggravation and generally speaking, you are the key to those exacerbations. Have you done something that aggravated you, are you not sleeping well, have you been under a great deal of stress, have you had reinjury, are you over doing it in your exercises and activities, or is your sitting or lying posture part of what is causing minor daily aggravations. A thorough search to understand the reasons for the aggravations is important. You must not continue to make the same mistakes over and over again.

REMEMBER! You cannot expect to get better if you are periodically or frequently reinjuring the areas involved in your musculoskeletal back pain problem. Injured tissue is extremely easy to reinjure and even the most minor injuries tend to be cumulative and exacerbating. You must maintain your activity and exercise intensity within your limitations and not stretch them everyday, as is often the case.

Copyright © 2002, E. Franklin Livingstone, MD

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