1. Positioning: Find a position of comfort to decrease strain on your low back

• Positioning is important for everybody, but it becomes especially relevant to a person suffering from acute LBP. In 1964, Nachemson et al studied the amount of pressure placed on the 3rd and 4th lumbar discs in different postures, and showed that sitting puts the most pressure on your low back, followed by standing (30% less pressure than sitting), then sidelying, then lying flat on your back, and lastly lying on your back with your feet up over a bolster.  Is it any wonder that people who sit all day long tend to have more symptoms in their low backs?  Keep this in mind throughout the day.  If you sit a lot, take breaks every 20 minutes or so to stand up, walk around, and decrease the static strain on your low back.
• Your position of comfort should be pain-free, and all areas of your body should be supported, including your head and neck.  Perhaps most importantly, you need to be able to get into and out of your position of comfort without increasing the pain and strain on your low back.

2. Pain Management: Ice,  heat, supplements, and pain medication

• There is value to the use of ice or heat for the management of LBP.  To apply ice, place an ice pack or a bag of crushed ice (a bag of frozen peas will work too) on the area of pain, ideally while in your position of comfort.  Use a thin dry cloth or a damp warm towel between the skin and the ice.  Ice for no longer than 15-20 minutes.  In acute “flare-ups” ice as often as 3-4 times per day for the first 2-3 days.  Some people are extremely sensitive to ice and cold, and should use caution when applying ice.
• Heat is okay for LBP that is more chronic in nature, meaning that the acute inflammatory phase of healing has passed (at least 2-3 days following injury).  Methods of heat application include a hot shower, and heat pack, or a hot tub/bath.
• A physician should be consulted prior to taking any pain medication.  Typical medications prescribed for LBP include muscle relaxants, tylenol, aspirin, and opioid analgesics such as vicodin.  There is a difference between pain medication and anti-inflammatory medication.  For more information contact your physician, and also read this article!
• Fish oil supplements have been shown to help reduce back pains in the long run. Here are some of the best fish oil supplements out there.

3. Posture: Efficient alignment of your bones and joints

• Throughout the course of a typical day, we rarely have time to relax in our position of comfort. Rather, we stand or sit for the majority of our waking hours.  Think of how you stand.  In the pictures on the right, the person on the left stands with efficient posture.  The force of gravity acts on this person’s body in a way that all of the weight from the head, arms, and trunk (HAT) is transferred into their feet (their base of support). Note how relaxed this posture appears. The other postures shown to the right demonstrate either holding patterns, in which excessive muscle activation is needed to maintain a posture (such as the military posture in the middle), or hinging patterns, in which the weight of the HAT comes to rest on a particular region of the spine (a “hinge point”).  For example if someone were to push straight down on the shoulders of the second person from the left,  they would either bend forward through their thoracic spine (midback), or “hinge” in their lumbar spine (low back).  This hinge point becomes hypermobile over time and can create imbalances throughout the spine, predisposing a person to degenerative changes (bone loss) or injury.
• Sitting posture is also critically important to maintaining a healthy spine.  Read this article for more information on sitting postures and ways to improve ergonomics! And because our muscles heal during deep sleep, sleep posture is critical as well.  Keep in mind what we discussed above under Positioning, and read this article for more information on sleep posture!

4. Appropriate Movement: Decrease strain in your low back by following these tips

• Avoid aggravating activities: If a particular movement or activity causes pain and discomfort, avoid that movement or activity temporarily until the pain subsides.  If it is impossible to avoid because of your job or lifestyle, at least consider ways in which you can modify an activity to decrease strain on your low back.
• Hip hinge: A hip hinge involves leaning forward with your upper body while maintaining a neutral spine.  During activities such as shaving (for guys)/putting on makeup (for women), brushing your teeth, or washing dishes  we tend to lean over the counter by bending in the low back.  This creates tremendous strain in the structures of the spine, particularly the discs and facets.  Instead of bending from the low back, keep the spine neutral and allow yourself to bend forward from the hips.  This also comes in handy when standing up from a chair.
• Use your legs: This is cliche advice, but it is rarely followed to its intended extent, partially because many of us are not strong enough in our legs.  Working on lower body strength will help decrease strain in your low back, if you are using good mechanics.  But “using your legs” means more than just having strong legs.  To decrease strain in your low back it is essential that you learn to accept weight into your legs.  A good example of this involves sitting.  If you can easily lift your legs off the floor while sitting, then you are not accepting enough weight into your legs.  And if you aren’t accepting weight into your legs, much more pressure is placed on your lumbar spine.  Another way to use this information, and an alternative version of the hip hinge, would be to stand in a stride stance while washing dishes or performing one of the aforementioned activities.  Keeping a neutral spine, allow yourself to bend forward (from the hips), and feel how much weight you have accepted into your front leg.
• Lift wisely: When lifting objects (not just heavy objects), keep these tips in mind:

1. Use a wide base of support: keep your feet at least shoulder width apart
2. Keep the object as close to you as possible
3. Keep the lumbar spine in a neutral position: think of the hip hinge
4. Brace by contracting your deep abdominal muscles
5. Do not twist or rotate while lifting objects

5. Exercise: The best treatment for low back pain

• Exercise helps to decrease pain and increase function.  In 2008 The Spine Journal published information compiled from many different individual research journals.  They determined that exercise is more effective in the management of LBP than spinal injections, spine surgeries, medications, and physical modalities and traction.  Perhaps most interesting, they concluded that a general exercise program is just as beneficial in the management of low back pain as core stabilization exercises.  Lifting technique is critical!
• That being said, when suffering from acute, irritable LBP, “general exercise” may not be possible due to pain and symptoms. Here are five low intensity exercises that can be performed gradually when recovering from LBP.  The purpose of these exercises is to increase strength, range of motion, and coordination in the low back, as well as to decrease the fear of movement.  They can also be performed as a warmup for anyone!

1. Feldenkrais pelvic clocks: Lie on your back with your knees up and feet flat on the floor.  Imagine that your pelvis is a bowl and slowly tilt your pelvis down towards your feet (12 O’clock), and up towards your head (6 O’clock).  As you move towards 12 O’clock there should be a subtle extension/arching of the low back.  This is good, but the emphasis of the exercise is not to extend the low back.  The emphasis of this exercise is to move from the pelvis.  When moving your pelvis towards 6 O’clock there will be a subtle flexion/flattening of the low back.  Using these two points as a reference, begin to explore other points on the clock, from 1 O’clock to 11 O’clock, and every point in between.  Take this exercise slowly and make sure that you are not straining your back to perform these movements.  If you are, then decrease the size of your movements.
2. Bridging: Lie on your back with your knees up and feet flat on the floor.  Keep your spine in a neutral position as you use your hamstrings and glutes to push your pelvis up towards the ceiling. Don’t go too far and don’t extend your spine!  Begin with a small range of motion and let your symptoms guide you.  If it is easy, push yourself a little harder.  If it is difficult, back off a little bit.  Try to do 10 repetitions 2-3 times, with a 1 minute rest in between.
3. McKenzie prone press-ups: Lie on your stomach with your elbows positioned directly beneathyour shoulders and your hands flat on the ground in front of you.  Gently push your chest off of the ground.  There should be no active contraction of your low back extensors, and there should be no pain in your low back. Allow your arms to do all of the work.  Hold this position for about 30 seconds and then relax for 30 seconds.  Repeat 2-3 times.
4. Child’s pose with arms outstretched: In kneeling, spread your knees apart slightly, keeping your feet together.  Then shift your weight back and sit on your feet, keeping your arms outstretched in front of you.  Relax into the stretch while reaching out with your arms.  While holding the stretch walk your fingertips to either side, and feel how the stretch increases on the opposite side.  Breath deeply and relax.  Hold each stretch for about 30 seconds and repeat 2-3 times.  If flexing your low back (bending forward) is painful, you can perform a similar stretch with your low back in extension (the position your back was in for MecKenzie prone press-ups).  Simply shift your weight forward, bringing your hips off of your ankles.  Slide your hands forward as your chest drops towards the floor, causing your back to sag downwards.  When you feel a good stretch in your low back and your arms, hold for about 30 seconds.  As with the other exercises, start with gently, slow, small movements, and let your symptoms guide you.  Do not stretch to the point of pain.
5. Cat/Camel Stretch in quadruped: Many people with LBP are familiar with this exercise.  Begin on all fours with your hands directly under your shoulders and your knees under your hips.  Gently arch your back (A) and hold for 5-10 seconds.  Then allow your back to sag down, bringing your stomach towards the floor (B).  Again, hold this for 5-10 seconds.  Alternate these movements to enhance motion throughout your spine.  A more advanced version of this exercise involves shifting your weight forward and back while holding each of these positions (cat/camel).  As you shift your weight forward and back you will notice the stretch targeting different parts of your spine, like a wave of increased tension.  Make sure that all movements are slow and prolonged, and again, let your symptoms be your guide.

• Maintaining flexibility through the hips and lower extremities is also critical in the management of LBP.  It is important to begin with gentle flexibility exercises that do not increase strain in your lumbar spine.  For a simple introduction to six low intensity yoga postures, read this article!

Much of this information has been modified from principles and concepts developed by The Institute of Physical Art (IPA), continuing education providers for physical therapists.  For more information on IPA, click here!

Low Back Pain (LBP) is an epidemic in our modern society. LBP is reported as the #1 reason for missed work and #2 reason for seeing a doctor. According to National Institute of Neurologic Disorders and Stroke (NINDS), Americans spend over $50 billion each year on the evaluation, diagnosis, and treatment of LBP. It is the second most common “neurological ailment”; second only to headaches. Many clinicians and researchers estimate that 70-85% of people will experience LBP at some point in their lifetime.

AN ANATOMICAL APPROACH TO THE PROBLEM

LBP is a “catch-all” diagnosis. There are many structures in the spine that can cause pain. It is important to see a physician for a diagnosis and a good physical therapist or chiropractor to address your particular movement impairments and functional limitations.  Here is a list of the most common causes of LBP:

• Intervertebral discs: There is a disc between each vertebrae.  These discs allow for smooth movement and shock absorption.  Discs are frequently injured as a result of repetitive activities and trauma and can degenerate with age (more on bone loss).  Terms used to describe disc injuries include “herniated disc” or “bulging disc”.  If a disc is the source of LBP, the pain is usually aggravated by bending and twisting motions. Activities such as reaching down to tie your shoes or sitting for a long period of time can increase pain.  Also, quick movements such as a cough or sneeze can be painful.  Pain may be felt on one or both sides of the spine, and can be accompanied by nerve root irritation.
• Facet joints: These are the joints that, along with the discs, connect adjacent vertebrae.  Often these joints become dysfunctional and restricted into certain movements.  Facet-induced LBP usually affects one side of the spine more than the other.  It generally stays more localized than disc pain.  Painful movements include extending the back, leaning towards the side that is painful, or twisting.  Activities such as walking, running or reaching behind you to pick something up may be painful.
• Soft tissue: This includes fascia, superficial muscle, deep muscle (read about muscle strains).  Pain associated with soft tissue restrictions can present in any number of ways depending on which tissue is involved.  Generally, an active contraction or stretch of the affected muscle will elicit symptoms.
• Nerve roots: This is often referred to as a “pinched nerve”.   Nerve root pain can be experienced locally in the back, but it can also radiate down into the buttox and legs (sometimes called radiculopathy or radicular symtpoms. “Sciatica” is an example of this.)  As aforementioned, an injury to the intervertebral discs can precipitate nerve root pain as well.  Nerves from the spinal cord exit the spinal canal thru foramina (holes) between each vertebrae.  If a disc is injured it can impinge upon a nerve (“pinch”), and this prolonged compression creates pain both in the spine and down the length of the nerve (some of these nerves go all the way to the feet!).  This pain can be aggravated by similar activities as were mentioned above in the section on intervertebral discs.
• Degenerative Changes: Discs can degenerative over time.  The vertebrae also can become compromised by degenerative changes such as arthritis.  Pain from “Degenerative Disc Disease” is variable.  EVERYTHING can cause pain; bending forward, leaning back, twisting, anything!  A common arthritic condition affecting the vertebrae is termed “Spinal Stenosis”.  This is a narrowing of the spinal canal or the foramina (“holes”) through which the nerve roots exit the spinal canal.  Stenosis often causes pain both in the back, and radiating into the lower extremities.  It is generally made worse when the back is extended (or fully erect to neutral) and thus leaning forward tends to ease the pain.
• Fracture: Compression fractures can occur due to a fall or impact injury.  A spondyloslisthesis can occur as a result of a fracture in a particular part of the vertebrae.  Pain from fractures varies.  Generally a compression fracture will result in pain with bending and twisting, while pain from a spondylolisthesis occurs while extending the back.  Diagnostic imaging is needed to confirm these diagnoses.

OTHER THINGS TO RULE OUT:

Only a physician can rule out other, potentially more serious causes of back pain. These include:

• Cancer: Some common questions used to determine a person’s susceptibility to cancer / likelihood of having cancer are: Do you have a prior history of cancer?  Do you have a family history of cancer?  Are you over 50 years old?  Have you experienced recent, unexplained weight loss?  Do you have a constant fever or night sweats?  Does the pain remain constant, even while resting?  If you answer yes to any of these questions it is typically a red flag, and a clinician will want to rule out cancer, using diagnostic tests.
• Referred Pain From Internal Organs: Some organs that can refer pain to the area of the lumbar spine include the ovaries, uterus, testes (pelvic organs), kidneys, urinary bladder (retroperitoneal organs), pancreas, large intestine, and the sigmoid colon (digestive organs).
• Abdominal Aortic Aneurysm (AAA): This is a sac formed by dilation of the wall of the aorta.  Pain associated with AAA has been described as throbbing and pulsating.  No postural or positional changes alleviate the pain.  This is a medical emergency!
• Endometriosis: A condition in which the tissue that normally lines the uterus (endometrium) grows in other areas of the body.  Signs and symptoms include pain, irregular bleeding, and possible infertility.
• Psychological Factors: Some say that the the mind induces physical pain to serve a psychological purpose (Dr. Sarno).  Under this theory, the pain serves to distract the mind from some more disturbing, repressed psychological conflict.  It is a form of self-preservation.  On the other end of the spectrum are those who believe that pain is purely physical.  The majority of health care practitioners recognize both the physical, structural mechanism for pain and the psychological and emotional factors that affect the pain.  A good definition of pain addresses both the mind and the body: “An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage” (from IASP, Subcommittee on Taxonomy, 1979).

LBP is an epidemic that is complex in nature.  Diagnostic and treatment approaches vary.  In Part 2 we will discuss some conservative treatments that can help manage LBP and hopefully alleviate the symptoms.