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Chronic Back Pain - Not Just a Bummer!! My Self-Help Story (and FYI My Back)


Very interesting article published in the Lancet revealed that chronic back pain was now the second most common cause of Disability Adjusted Life Years. Though age and BMI are certainly contributors, I am hesitant to dismiss remediable issues associated with the stereotypical American (though study was global) lifestyle (sedentary, increased time spent sitting hunched over a desk, near continuous staring down or typing into smartphones as well as a drive for instantaneous gratification: reliance on treatments providing quick symptom relief). I am convinced that a majority of people suffering from chronic back pain can, with or without the help of physical therapy (which I wholly support), feel better in the intermediate and long term. Hard work is required: including, at least, reading, increasing body awareness, avoiding maladaptive habits and putting significant effort into reversing the underlying issues that have resulted in back pain. A requisite corollary is willingness to rely less on "crutches" which can, at times, make the situation significantly worse.

DISCLAIMER!!

I have no formal training in any of the many disciplines used in some fashion by players in this huge "space" that is teeming with professionals, paraprofessionals, and others that provide "traditional," non-traditional, or bogus treatment. My focus will be on alterations in other parts of the kinetic chain, which indirectly can result in back pain. I am not a doctor (ok, I am) - I am not that kind of doctor. The information I provide should not be used in place of seeing your internist or a "specialist." Acute changes in motor, sensory or bowel/bladder dysfunction as well as recalcitrant or progressive symptoms should be evaluated.

I have exercised (strength > endurance training) nearly every day since I was 12. I was a personal trainer for a short time at a Jack Lalanne in Bensonhurst, Brooklyn in the early 80s.

I have bad cervical and lumbar spine arthritis/disk disease, which, for better or worse, has led to 2 cervical and 3 lumbar surgeries. I have a rod extending from C3 to C7.

This is MY story - the basic principles are true and specific somatic issues and treatment strategies are pertinent to many. Trial and error and determination are imperative if your goal is to ease this taxing symptom. The entirety of what you see below (greatly simplified) has worked for me. The salubrious effects of this "program" should extend far beyond back pain!

PRINCIPLES

1. Back pain may occur due to imbalances, weaknesses, inefficiencies or habit-related temporary or more permanent changes occurring anywhere along the kinetic chain, from head to toe. Structural or functional alterations in bones, joint, muscles or tendons may all be involved.

2. Because of the complex interdependence, pain in one area is often a consequence of pathology in another, usually more distal, e.g., low back pain related to asymmetric hips or to a collapsing medial longitudinal foot arch.

3. Intrinsic or extrinsic "compensation" for the primary issue may be helpful in the short term but deleterious over time, e.g. using foot orthotics to prevent foot overpronation - inward rolling often due to excess flattening of the medial longitudinal arch (see below) after ground strike resulting in poor shock absorption, with potential negative impact observed on the ankle, knee, hip and spine. Think of the "use it or lose it" phenomenon.

4. Bones are the strongest part of the "chain." In general, the most efficient, least injurious upright posture (while standing, walking or running) will maximize the time spent with the bony elements stacked (e.g., standing with the head balanced on the neck, hips, knees, ankles in a vertical line with even distribution of weight on both feet). During walking or running, the body weight has to be propelled forward, but over-striding, with the swing leg landing too far forward will stress the system.

 

Poor posture is almost universal!

 

Four prominent issues that frequently accompany the "sedentary lifestyle" (inactive, prolonged sitting, head down):

a. Anterior Pelvic Tilt (APT). Imagine the upright pelvis viewed as a cone (wider at the top than the bottom). With excess APT the front of the pelvis drops and the back of the pelvis rises (butt sticks out, lower belly protrudes, and the natural curve in the lower spine is exaggerated). It is almost universally seen in prolonged "sitters" and is characterized by shortened, "tight" hip flexors (illiopsoas) and loose, lengthened hip extensors (especially the hamstrings) as well as weak abs and spine extensors. Increased APT is not attractive and most experts believe it can cause significant low back pain.

b. Forward Head Position (FHP). The head should be balanced on the spine so that if you look in a mirror from the side, the ears should be in line with the neck and shoulders with the shoulders and neck muscles relaxed. With FHP, every inch of our massive heads are displaced forward applies 10 pounds of pressure on our cervical spine. It is not difficult to see the result.

c. Weak Intrinsic Foot Muscles. Seems only a few people "in the know" understand the vital importance of foot health. Dysfunction is both common and pernicious. The concept I found most vital was the need to be able to effectively form a "stable" foot tripod, with the center of the heel, the base of the first metatarsal (leading to the big toe) and the base of the fifth metatarsal (leading to the pinkie toe) making firm contact with the ground, providing a sturdy foundation which is especially important during the single leg stance portion of walking and, more importantly, running. A healthy arch, maintained by strong foot and anterior leg muscles is imperative.

d. Weak or "Sleeping" Gluteal Muscles. The glutes stabilize the lower spine and are the strongest hip extensors, primarily responsible for forward movement of the opposite leg and total center of gravity by "pushing the ground backwards" at toe-off. Due to their natural strength and the leverage advantage they have over your legs, the glutes should always be the primary muscles driving lower body movement. Not only does this include more ballistic activities like running and jumping, but also walking. "Modern life" often equates to overshadowed or, more commonly, "inhibited" glutes. Walk with your hands feeling each hemi-butt - it is likely that one or both don’t contract during the periods when they should be the "prime movers."

FIXES: What I have done to walk, run, cross train better and limit back pain

1. Components of a Multidimensional "Attack"

  • Learning, read-read-read, watch video after video, observe (including record and watch film of your posture, gait, etc)

  • Replacing previous unhealthy postural and movement patterns with desirable ones, requiring much trial and error

  • Strength and endurance training of appropriate muscles (often asymmetrically)

  • Stretching only what could be/needs to be stretched in ways that protect vulnerable joints, e.g., knees

  • Frequent reinforcement

  • Lifestyle changes to facilitate the above

2. Excess APT - ☑ - FIXED

  • Less sitting, frequent "breaks"

  • When sitting, avoid flexed legs, e.g., adjust car set

  • Bought a "standing desk" that can be adjusted - gradual increase in standing

  • Morning routine: glute bridges (left > right), prone glute recruitment, planks for abdominal muscle strenthening, hip flexor stretch, and avoidance of hamstring stretches as they were already long and loose (despite "feeling" tight)

3. FHP - ☑ - FIXED

  • Studied and utilized elements of the Alexander technique: head "floating" on spine, balanced - relaxed shoulders, down and back. If it is necessary to rotate head forward, do so from actual articulation with spine (up around ears) instead of allowing entire head to move forward and bending cervical spine

  • Frequent daily checks and corrections (mirror from side)

  • Morning routine: stretch muscles that move the head forward, head retraction exercises and "wall standing" with hips, shoulders and bottom of back of head all touching wall

  • Standing desk

  • Sleep on back (with practice using one small pillow placed under the back of my head only keeping my head-spine in a neutral position)

4. Footwork - ☑ - FIXED

  • Morning routine: soft tissue work on 3 foot arches using small hard foot massage ball, toe "waving," writing the alphabet in air with big toes, short foot exercise, single leg squats on foot tripod

  • Frequent daily repeat of above as well as "shuffle walk"

  • Slowly decrease "stack height" - vertical distance between heel and toe of daily footware-sneakers - developing more of a midfoot rather than heel strike

  • Eventually get rid of orthotics

5. Asymmetric and Inactive Glutes - ☑ - FIXED

  • Concentrate on waking up the glutes (especially on left) in all positions: supine, prone, standing - working on hip extension, external rotation and maintaining frontal plane stability with single leg stance

  • Morning routine: glute bridges

  • Periodic daily checks and corrections of glute activation with direct palpation with walking (when alone)

  • Lateral walk with theraband around thighs and, again, around forefoot (to maximize external rotation of hips)

SUPPLEMENTARY

  • Weekly massage

  • Yoga

  • Meditation

  • Avoidance of pain meds

  • Firmer bed -- A bad bed can be the undoing of a not-so-bad back. A soft bed allows a stiff link hiding in the spinal machinery to sag as the body gets heavier in sleep. This often happens on holiday when "that bed" caused untold mischief. Of course, a soft bed is often seductively cuddly and welcoming on first getting in. It yields to your pointy shoulder or hip bone and cossets your tired body after a long day. But a bed that is too soft will let you down through the night. A bed that is too soft will not give your spine the support it needs ~ and by this I mean in short, a soft bed will contribute to causing a painful back. I bought a Sleep number bed - appealing because trial and error is easily accomplished.

CONCLUSION

I am convinced despite absence of universal consensus on almost anything I’ve discussed--the stereotypical American lifestyle/body mechanics is responsible for a huge percentage of chronic back pain. The good news is with self-study +/- aid from various paraprofessionals--top-notch massage therapists, physical therapists, podiatrists, personal trainers, chiropractors, etc. much of the burden can be alleviated, sparing major surgery in many cases.

USEFUL LINKS and REFERENCES

  • My favorite article (actually a chapter) with a comprehensive look at the kinetic chain, posture and locomotion: http://www.chiro.org/ACAPress/Body_Alignment.html?

  • Short, simple video reviewing "the gait cycle": https://youtu.be/5j4YRHf6Iyo

  • The Gait Guys: All I can say is they are PHENOMENAL! Find them on Facebook, Tumblr, and many incredible podcasts. They are prolific and super bright. Here is one link of many on controlling the MLA and the foot tripod: https://www.youtube.com/watch?v=TyRE9dReVTE&feature=youtu.be-

  • Stretching: Best book I've found - Stretching and Flexibility (2014) by Kit Laughlin

  • Standing desk: Very happy with varsidesk: http://www.varidesk.com/

  • "Wake up the Glutes": One of many excellent videos: http://redefiningstrength.com/glute-activation-10-exercises

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