Positive Health Online

It is staggering to think that back pain will affect so many adults. Back pain in its various forms will affect 80% of people at some stage during their adult lives. This is the grim news given to us by the National Back Pain Society.

In that respect, we know much about back pain. Its common occurrence amongst the population has taught us that the condition can be brought on by even simple movements. Back injuries would seem to be difficult disabilities to cure and rehabilitate. A person who has had a bout of backache is ten times more likely to have another backache than an individual who has never suffered.

We know these bouts get progressively worse but 90% of the time the pain symptoms will disappear whether the patient receives treatment or not.

Postural Strains and Sprains. Poor posture and working habits place excessive strain on muscles,
ligaments and joints.  Far Right: The sections of the spine.

Every day in America, 2.5 million people are incapacitated by back pain. These people's lives are turned upside down for the period of back pain. It seems they are penalised by a medical condition they have no warning of and can do little to effect recovery from.

Our National Health Service back pain bill is running at £480 million a year, but this is a drop in the ocean compared to figures produced by the Confederation of British Industry. They put the cost of work absenteeism at £12 billion annually. Back problems are estimated to account for 40% of all absenteeism.

In light of this evidence, surely more should be done to address this extraordinary situation.

The pain and expense of back problems are fundamentally unnecessary. Although there are no magic solutions, the answers to solve much of this dilemma are available.

It is time to take a new, fresh look at PREVENTION of back injuries rather than face the frustration of treating them after they have occurred. Back problems can be prevented most of the time. Effective education is the key. Understanding the problems, how to prevent them and what to do if they occur are the answers. It involves self-responsibility and a desire to have a healthy back.

This is the successful philosophy of Duane Saunders, a leading Physical Therapist from America whose ideas and back care programmes are widely utilised all around the world today. As Duane Saunders says himself, "We know how to prevent and treat most musculoskeletal disorders. Perhaps the most frustrating obstacle now is the difficult task of communicating this information to everyone who needs to know it, from health care professionals to business and industry leaders and most importantly to patients and workers."

Today, most patients visiting Duane Saunders' clinics soon realise that physical therapy is not just about the application of localised treatments and exercise, but the application of a comprehensive, systematic approach to the patient's problem. The physical therapist's role involves the area of patient evaluation, problem assessment, treatment planning, application of treatment techniques, reassessment, modification of treatment programme, rehabilitation, education, motivation and prevention.

This approach individualises the programme and, vitally, asks the patient to examine what aspects of their lifestyle may be putting them at risk to back pain.

In this way, efforts to provide treatments are not limited to the acute phase only. Along with treating the symptoms such as pain, inflammation and muscle guarding, there will be an emphasis to evaluate and treat function or to address the problem which caused the disorder to occur in the first place.

Treatment must be more than passive and involves the active participation of the patient. Rest, medication, heat, electrotherapy through to surgery are all examples of passive treatment that do not require the patient's active participation.

Back pain is rarely the result of one incident or injury. One of the keys to having a healthy back is understanding that most back injuries are the result of the cumulative effects of months or even years of poor posture, faulty body mechanics, stressful living and working habits, loss of flexibility and strength and a general lack of physical fitness.

A back disorder begins to develop long before the first episode of pain is experienced and the problem is usually still there after the episode of pain subsides. Actually, this minor injury irritates the stiff and weak soft tissue structures in the back causing a painful episode of muscle spasm and inflammation. As the pain episode runs its course, the important treatment becomes preventing the next episode. So prevention and treatment principles are really the same.

The patient's positive attitude and proactive involvement to effect the key issues such as sitting slumped, posture, weak abdominal muscles, tight hamstring muscles as well as emotional tension is paramount to recovery.

This is because a vast number of people live in a lifestyle that almost predisposes them to become victims of back pain. The way people earn their living and spend their leisure time dictates that the posture they adopt to perform these varying tasks puts pressure on the spine and supporting structures which over a period of time causes stiffness and weakness. The foundations have been laid for a problem back.

Some may find it surprising that 90% of all back pain reported occurs in the lower lumbar spine. If we look at this area in its relation to adopted posture, we can see why.

In focusing on some of the functions of the spine we see the four curves of the spine (fig 1.) Sacral, Lumbar, Thoracic and Cervical reciprocate and balance one another in such a way that in the normal spine, if a plumb line were dropped from the atlanto/occipital joint at the top of the column, it would intersect the centre of motion at the lumbosacral junction at the bottom.

These curves not only provide balance, they provide added strength for the vertebral column to withstand axil compression loads. Engineers have calculated that the presence of the three curves (excluding the sacrum) increases the resistance of spine compression ten times compared to a column with no curves at all. The sitting slumped or forward leaning "adapted posture" to accommodate working on a computer, on a production line, driving, watching television, and a hundred other lifestyle activities, tends to straighten the lumbar spine, increasing intradiscal pressure on this area, the lower back.

The work of Nachemson provides data concerning intradiscal pressures. Sitting and forward bending of the spine causes greater intradiscal pressures than the upright standing posture.

In particular, the inexorable infiltration of our working lives by personal computers is partly responsible for what almost accounts to an epidemic of musculoskeletal symptoms amongst the office population.

In 1976, there was a total of 675,000 people working with computers in America. At the current rate of increase, it is estimated that by the end of this century, 75% of all working activities will involve the use of display screen equipment.

To illustrate the point and the effect that your working environment can have on the spine, let's look at the experiences of one individual. Darren is a 29 year old man with a history of back problems. Indeed at the age of 21, Darren had already had surgery on his spine.

At the time, Darren was working as a car mechanic. This meant a great deal of his time was spent in the adopted working posture of being slumped forward, leaning over the engine of a car.

He was advised that such 'heavy' work may not be appropriate and to look for an alternative type of employment. Being a positive person and in light of the fact that he believed he was now cured of his back pain, he took the advice and retrained to work with computers.

Unfortunately, this change of occupation was a little like jumping out of the frying pan and into the fire! After a few years of being pain free, his back problem started to return, intermittently at first. His new adopted working posture was slumped forward sitting at his computer workstation, therefore, not surprisingly, his pain eventually returned in full. However, his attitude had changed. He saw no benefit to be gained from further surgery. Surgery had not solved his problem first time around so why should it now?

When Darren first visited a Saunders Clinic in Minneapolis in 1995, he was totally incapacitated. He literally had a back that was as flat and stiff as a board. This lumbar flexion syndrome (flat back) is characterised by the patient who slumps with a flattened lumbar spine while sitting or standing.

Like most people, Darren was astonished when informed that sitting at a computer for a few hours is far more physically taxing than a jog in the park! His static sitting posture would force the spine to take the entire body weight for extended periods of time.

Darren confirmed to his physical therapist that at first the pain was intermittent and only came on after being in a flexed postural position for a while. Coming to the standing position after prolonged sitting was becoming especially difficult and painful. He also reported that changing his posture or position usually brought relief from pain.

In this lumbar flexion condition, ligaments are maintained under prolonged tension and will adaptively lengthen. So the ligaments stabilising the spine in flexion are all subject to stretch. Once stretched beyond normal resting lengths, support for the spinal column is lessened.

The resulting pain is often bilateral and may refer symptoms to the extremities. Early on in the condition, full mobility is present, but prolonged maintenance of the flattened lumbar posture will eventually lead to a loss of lumbar extension.

When Darren finished his initial assessment, he was a little depressed but left agreeing to come back to the next session having inwardly digested the education material contained within the Saunders Self Help Manual For Your Back.

From this point onwards, he took an active interest in his treatment. Realising that in the longer term he was the only person who could affect his problem. This positively inspired him.

Some of the early treatments to mobilise and manipulate his spine were fairly aggressive including sessions of traction to assist extension of the lumbar spine. It was essential to mobilise the spine so that backward bending flexibility could be regained and a proper balanced posture be achieved and maintained.

Darren worked hard and learned quickly that regaining better function of the spine was only the first step. His exercise regime was progressive and changed as the function of his lumbar spine returned. By week five of his treatment Darren was on the mend, and, able to gain some extension in his lower back, he already started to plan his return to work. This he was able to do with more confidence, knowing he could help himself to avoid postures which caused his problem. Rather than change his job, he provided himself with proper office ergonomics. A fully adjustable chair which provided a lumbar support and equipment organised to suit his corrected working posture.

When driving he used a lumbar cushion and ensured that whatever activity he was performing, regular breaks for backward bending and exercise were necessary to maintain a full range of motion in extension and to strengthen back muscles.

Incorporating more regular rest and relaxation into his activities list further increased both his recovery rate and his zest for life. So much so, that with the use of a properly fitted Saunders S'port All Back Support, he was able to return to playing his favourite sport of basketball, something he had not been able to do for years.

Prevention has always been better than the cure, but in our 'easy life' designed for comfort and convenience the ability to recognise and correct potentially damaging situations to the spine is essential.

Text Reference

Evaluation, Treatment and Prevention of Musculoskeletal Disorders – Volume I Spine – H. Duane Saunders