The other day, I drove past a man doing yard work, and the first thing that caught my eye was that he was wearing a back brace. It was one of those black, stretchy bands that went around his waist with straps over his shoulders. Being a PT, I of course wondered what type of injury he may have had in the past or if he was wearing it as a preventative measure, a sort of reminder to keep his back safe and use good lifting techniques.

Well, with much concern I watched as he bent over, lifted a huge bag of mulch, and twisted at the waist as he moved it over. He might as well have never bothered with the brace. It won’t prevent any trauma or injury to the spine, but provides some warmth and gentle compression/comfort for the spine, and can often times be a reminder to use good body mechanics on order to avoid back injuries.

So, for those of you out there wearing back braces, allow them to be a tool for increasing your awareness of your posture and how you use and move your body. Don’t rely on them as a means of external support and protection, or you may be disappointed.

An often overlooked muscle group when it comes to stabilization exercises for the pelvis and low back are the pelvic floor muscles (the levator ani and coccygeus). This is a group of muscles that connect from the front of the pubic bone to the tailbone. They create a hammock between the legs and assist in stabilizing the pelvis as well as supporting the abdominal organs, particularly the bladder and bowels.

Weakness in the pelvic floor muscles can contribute to back pain, sacroiliac joint pain, pubic symphysis pain, as well as incontinence (leakage of urine) when you cough or sneeze. Dysfunction in the pelvic floor muscles can be due to trauma, as a result of childbirth, or due to poor posture with associated muscle imbalances.

To exercise the pelvic floor muscles, try to envision pulling the muscles of the saddle area up and in towards your abdominal cavity. You should not feel your buttocks, thighs, or abdominals tightening as you do this. One of the simplest ways to learn to contract the pelvic floor is to stop the flow of urine while you are on the toilet. You can try this technique to verify which muscles to isolate, but avoid doing this often, as it can cause urinary tract infections.

This type of pelvic floor contraction is also known as Kegel exercises. Though it can be difficult to learn how to isolate these muscles, they are an important component of a lumbosacral rehabilitation program. (They’re also very important to do throughout pregnancy and immediately following birth in order to prevent and manage incontinence.) If you are not certain that you are performing these with the correct technique, discuss it with your health care provider or physical therapist.

Well, I didn’t make it to watch the 11:00 news last night, but I did read the story this morning. Check out this link to see why one New York doctor thinks the cure to back pain is all in your head.

http://www.thebostonchannel.com/health/16301412/detail.html

It seems there are always new products, gimmicks, exercise plans, and support groups that claim to offer the most effective, latest and greatest forms of weight loss. I see it on TV, in magazines, newspapers, and I even received a marketing piece in the mail the other day claiming to be the solution to my weight loss problem (which I incidentally don’t have).

I’m starting to hear and see a lot of the same about back pain. On the radio today they were promoting the newest “controversial” cure for back pain that is supposed to be highlighted on the 11pm news (I hope I stay awake long enough to see it). There are a slew of new products from braces, supports, pillows, and supplements. Not to mention, many, often contradicting types of exercise programs. Even the physical therapy treatments range from very aggressive, to passive and gentle. So how do you know where to start or what to invest in?

I wish there was an easy answer…and if there is, I unfortunately don’t have it. I don’t think there is a magic answer to back pain and for many reasons. Here goes:

1. Every body is different and will respond differently to each product and treatment available.

2. Mental /emotional pain and stress will often contribute to physical pain and if not addressed, the individual may not experience relief from a given remedy.

3. Motivation and commitment make a huge difference. If you are supposed to wear a brace for a certain number of hours a day but don’t, the results may not be as implied. Or if an exercise program takes an hour and you only find 15 minutes, you’re not going to get results.

4. It’s often difficult for me to bring up the topic with patients who are overweight, but finding a weight management program is often needed to find relief from back pain. As hard as it is to lose weight, it is so important to make lifestyle changes that include healthy, mindful eating and exercise.

5. The spine is complex structurally, with so many joints, ligaments, muscles, discs, and nerve, that there is lots of room for things to go wrong. Any imbalance can create pain and result in muscle spasm that can lead to weakness and loss of motion over even a short period of time.

6. If there was a magic answer, there wouldn’t be so many resources, products, and treatments available.

I encourage people to tackle back pain quickly to prevent a chronic problem from developing. If one treatment isn’t successful and you are consistently following through with whatever components were recommended (you have to be honest with yourself here), then discuss alternative approaches with your current provider or seek out complementary treatments. Evaluate your lifestyle and overall physical and mental well-being to see what other directions you may need to follow for treatment. Keep an open mind and open lines of communication between all of your providers so you can achieve the best outcome possible.

And who knows, maybe the 11 o’clock news tonight will have a miraculous break through treatment new to all of us that will put an end to back pain forever.

My friend’s mom is newly diagnosed with spinal stenosis. She began to experience back pain a couple of months ago and her primary doctor referred her to physical therapy with a diagnosis of a bulging disc based upon her symptom: back pain that radiated down her leg.

Based upon her diagnosis, her therapists had her working on spinal extension exercises based upon the McKenzie method. These exercises encourage back bending of the spine and are designed to encourage the disc to migrate back into position, thereby relieving pressure on neighboring nerve roots. She did not improve, and in fact she experienced an increase in pain and further loss of function. Everyday walking and going to her gardening club became impossible.

She was then referred to a specialist who ordered an MRI. The results revealed that she has significant spinal stenosis. This condition also causes pressure on nerve roots due to arthritic changes around the spinal column which result in crowding of the canal.

In general, people with spinal stenosis respond well to flexion, or forward bending exercises, which help to open up the stiff, crowded joint spaces in the spine. This is quite the opposite of what she experienced in her first go around with physical therapy.

As a result of her negative experience, she opted to try acupuncture and steroid injections into her spine. I have tried to encourage her to resume some exercise, such as stationary cycling, or gentle water exercise. Walking, which naturally promotes spinal extension, truly aggravates her symptoms, but doing no exercise will only exacerbate the stiffness and mobility limitations within her spine. She is still reluctant, and rightfully so given her current pain level and her prior PT treatments…which were unfortunately for the incorrect diagnosis.

I don’t think her primary doctor is to blame here. Doctors must make their best educated diagnosis based upon a patient’s presenting symptoms and in these days of managed care, do try to avoid ordering expensive tests, such as an MRI until necessary. Many of my patients with back pain come to physical therapy before MRIs are performed, and many do in fact get better without having a confirmed diagnosis. In this instance, however, an earlier MRI may have resulted in a better outcome. Earlier access to the appropriate form of physical therapy or other treatment may have provided more rapid relief of pain and prevented a decline in her function and activity level.

Many of my patients with back pain experience an increase in pain when they get in and out of bed. And believe it or not, there is a right and a wrong way to get out of bed, or at least a way to do it that minimizes the forces on the spine.

If you are on your back, roll onto your side with your knees bent. If you are a side sleeper, you will already be in this position. Bring your legs over the side of the bed as you simultaneously push your torso up to a sitting position. The incorrect method is to transition from supine (flat on your back) to a long sitting position (sitting with legs straight in front of you). This movement requires significant abdominal strength and places strain on the lower back. Particularly if you have tight hamstrings and upper back muscles, this will be a difficult and potentially aggravating way to do it.

Using this “logroll” technique to get back into bed is also effective. Start by sitting at the edge of the bed. Start to lower onto one arm as you bring your legs up with the knees bent, into a side lying position. Keeping the knees bent, you can then roll onto your back.

This is the time of year when many of my patients express frustration at not being ableto enjoy gardening because of pain or an injury. Personally, I look forward to making changes to my perennial garden and planning our vegetable and herb garden each spring. And though I’m careful and try to be safe, there are evenings where I find myself sore from a day’s worth of digging and planting.

The back, neck, knees, and shoulders are often taxed with the various motions and positions assumed while tending to a garden. Kneeling, for example can be hard put a lot of pressure on the knee joint and bursa. Squatting repeatedly or for sustained periods can be aggravating to the knees, low back, pelvis, and hips. Raking, weed pulling, and digging require the neck and shoudlers to do a lot of work. So what’s a gardener to do?

I always promote the use of proper body mechanics, however I am realistic too. It’s often difficult to keep the joints in neutral alignment whn working in the garden. In situations where the body is under stress or working in a less than ideal alignment, the following tips may help prevent soreness and injury:

1. Vary your position every 5-10 minutes. Alternate between half kneeling on one knee, kneeling on both knees, and squatting when working low to the ground. It’s also a good idea to vary between standing and squatting to minimize the likelihood of strain to the joints and overuse type injuries.
2. Stretch often. Every 10-15 minutes, do a few simple stretches. Since a lot of positions I find myself in when gardening involve bending forward, I try to do stretches where I bend backward. Placing the hands on the lower back and gently arching back while standing is a nice way to stretch the front of the body. You can also do various stretches for the neck, chest, hip, and hamstring. This gives the muscles a well deserved break, allows better circulation to reach the tissues, and helps restore symmetry and balance to the body.
3. Don’t overdo it. (This is where I often go wrong.) I sometimes get on such a roll and can be in the garden for hours working. Try to limit the length of time you spend to perhaps one hour, maybe more or less, each day.
4. Sit back and enjoy. Allow yourself time to relax and take in the sights and sounds in your garden, even if you aren’t finished.

Sitting on the floor may be something you do often, or for some it may be a position they never assume. Personally, I never felt comfortable sitting on the floor, but when I had children, I found myself constantly on the floor with them. I would vary my position between sitting cross legged, kneeling, lying on my side, or propped up on my elbows while on my stomach. These frequent position changes helped my stave off stiffness and soreness, but it still wasn’t ideal to change my posture every few minutes.

As my yoga practice deepened, I began doing more spine and hip opening postures which certainly helped in terms of flexibility for being able to maintain these seated on the floor positions. The other technique I applied at home was to sit on a bolster pillow or folded blanket to help lift my hips up a little. By lifting the hips higher than my knees, the pressure on the muscles along the spine is reduced, and I am able to maintain these seated positions for longer periods and feel much more comfortable doing so. With my hips elevated, I can vary between sitting with my legs crossed, with my legs straight out in front of me, or with my legs out to the sides. It has helped me to gain better strength through sitting with an upright spine, and also improved the flexibility of my hamstrings and thighs.

You can experiment with sitting on a firm, folded blanket or a firm pillow. Allow your “sit bones” (the bony prominences within the flesh of the buttocks also known as the ischial tuberosities) to rest at the front edge of the blanket, so the pelvis starts to spill forward slightly, bringing the lower spine into it’s natural curve. This alignment through the lower spine translates to better posture through the ribcage, upper back, shoulders, and neck. If you find this to be particularly helpful, I recommend investing in a yoga bolster. They are made specifically to aid with seated postures on the floor and are the right size and firmness for doing this.

As always, listen to and respect your body. If something doesn’t feel right to you (stiffness, aching, throbbing, or other pain/discomfort), immediately bring awareness to your body, change your position, and eliminate the strain on your body. This will help reduce the likelihood of and assist in recovery from musculoskeletal injuries.

Back pain during the childbearing year affects up to 80% of women as a result of the vast changes happening in the body as the baby grows. During pregnancy, the joints throughout the body become more mobile due to the production of several hormones. The spine is therefore more easily sprained or pulled into sub-optimal alignment. This can result in muscle spasm, inflammation, pain, and a decrease in functional and recreational activities. In addition, women gain on average 25-35 pounds over a short period of time, with the majority of that weight distributed at the abdomen and breasts. This change in her shape shifts the woman’s center of gravity forward and upward, resulting in changes in her posture. She tends to stand with an excess arch in her lower back and her upper back rounded forward. These postural changes place stress on the muscles and ligaments surrounding the spine which can also lead to pain and functional limitations. Although back pain during pregnancy is a common problem, it often goes untreated as it is often perceived as an inevitable side effect of pregnancy.

Research findings suggest that the majority of cases of pregnancy-related back pain go unreported, with only a third of women discussing the problem with their maternity providers. Within that group, only 25% of their providers recommended a specific form of treatment.1 Women do not, however, have to suffer through their pregnancies with back pain. There are several safe, effective treatments that can help them manage their pain and optimize their well-being throughout pregnancy and into the postpartum period. A description of each follows, as well as some pros and cons.

Independent Exercise Program

Exercise is beneficial in preventing back pain, as well as helping to manage and reduce existing pain. In fact, research findings suggest that regular exercise during pregnancy can result in a significant reduction in the intensity of back pain. 2,3 Achieving a good balance between the strength and flexibility of the muscles surrounding the spine and pelvis can help provide stability and decrease the risk of injuries. In particular, the abdominal, back, and pelvic floor muscles should be targeted, as they are often most impacted by the physical changes that occur during pregnancy. Prenatal fitness classes offer a nice way for women to improve their cardiovascular fitness, strength, and flexibility, with the added benefit of socializing with other women. Prenatal yoga and Pilates are nice options as they target the spinal stabilizing muscles while focusing on alignment and posture. If such classes are not accessible or affordable, there are numerous book and video resources that can help women design their own programs.

Pros:

• May help prevent pain
• Can do exercise when it’s convenient
• Inexpensive
• Can use as an adjunct to individualized treatments for optimal results

Cons:

• If exercises are done incorrectly, pain and injury could result
• If lacking motivation, women may not be consistent with an exercise program
• Exercise may not be suitable for women with high risk pregnancies

If attempts to exercise independently are unsuccessful or pain initially prohibits exercise, individualized treatment by one of the following professionals could be beneficial.

Physical Therapy

A physical therapist experienced in treating pregnant women can evaluate the woman’s posture, spinal and pelvic alignment, joint mobility, muscle flexibility, strength, and tone. The physical therapist can perform safe, gentle techniques to re-align joints, improve joint motion, and reduce muscle spasm. In addition, a physical therapist can design an exercise program specific to the client’s needs in terms of muscle strength and flexibility, as well as teaching her how to move, position herself during sleep, and optimize her posture during daily activities. The treatment modalities physical therapists commonly use, including ultrasound and electrical stimulation, are for the most part contraindicated during pregnancy, but moist heat or cold packs could be used to help reduce pain and spasm.

Pros:

• Postural re-training will help during pregnancy and throughout motherhood to decrease stress to the spine, thereby decreasing risk of injury
• The pregnant woman can stop seeing the physical therapist and continue independently with her individually designed exercise program once she is ready
• Most health insurance covers the cost of physical therapy minus a co-payment

Cons:

• Depending on the facility, patients may not receive one on one treatment
• Not all therapists are experienced in treating pregnant women, so it is advised to inquire with local facilities to find an experienced provider

Massage Therapy

A massage therapist trained in prenatal massage will evaluate the client’s muscle tone and address any areas of tightness or restriction. The pregnant woman may be treated on her side, and some massage therapists use special pillows with a cutout for the abdomen so the woman can lie on her belly. Using various techniques, the massage therapist can help improve the circulation to the muscles, reduce stress, and promote relaxation, which can in turn improve posture. One study also found that pregnant women receiving massage therapy for 20 minutes twice a week experienced less anxiety, improved mood, better sleep, and a reduction in back pain.4

Pros:

• Improves circulation to muscles in pain or spasm
• Promotes relaxation and improved posture
• Gives the pregnant women an opportunity to rest and unwind, which is often much needed

Cons:

• Can be costly, even if subsidized by insurance
• Without exercise to help address muscle weakness and inflexibility, relief may be temporary
• As with physical therapists, one should find a massage therapist trained in prenatal massage

Chiropractor

A chiropractor experienced in treating pregnant women will assess the client’s posture, alignment, muscle tone, and mobility for regions of restricted movement or mal-alignment which would contribute to swelling, pain, and muscle spasm. S/he will then use various techniques to adjust, manipulate, or realign the joints. This restoration of joint positioning helps to reduce pain and improve movement and function. Some chiropractors will also recommend appropriate stretching and strengthening exercises to help maintain the corrections in alignment. In addition, one study found that women with back pain who were treated with spinal manipulation experienced less back pain during labor. 5

Pros:

• An effective way to correct an alignment problem
• Can sometimes provide immediate relief
• Effective if done in conjunction with the appropriate stretching and stabilization exercises

Cons:

• Can be costly depending on insurance
• Manipulating joints that are already more mobile (as a result of hormonal changes) could result in pain and injury if done incorrectly, so it is important to work with a chiropractor experienced in treating pregnant women
• If done without incorporating exercise, relief may be temporary

Acupuncture

Acupuncture, an ancient form of Chinese medicine, continues to gain popularity as a treatment for back pain in the general population. Recent studies have found that acupuncture helps improve function and reduce the intensity of back pain during pregnancy.6 An acupuncturist will perform a comprehensive exam including an evaluation of the client’s appearance, color, speech, pulses, tongue, and physical condition to determine where the flow of energy is obstructed. The treatment consists of fine needles (generally painless) being inserted into specific points throughout the body to help open the energy channels, thereby restoring balance, reducing pain and muscle spasm, and improving mobility. Acupuncture is safe during pregnancy, with the exception of specific points around the ankle that may stimulate the uterus.

Pros:

• A safe alternative treatment for back pain and restoring good flow of energy
• May also help reduce morning sickness in early pregnancy

Cons:

• Can be costly depending on insurance
• Patients need to be open and receptive to a alternative medicine
• People who fear needles may be intimidated by it

It is important to discuss with your OB/GYN or midwife to determine what type of treatment is best suited for you.

1 Wang, S et al. Low back pain during pregnancy: Prevalence, risk factors, and outcomes. Obstet Gynecol 2004 Jul;104(1):65-70.

2 Garshasbi, A, et al. The effect of exercise on the intensity of low back pain in pregnant women. Int J Gynaecol Obstet. 2005 Mar;88(3):271-5.

3 Kihlstrand, M et al. Water-gymnastics reduced the intensity of back/low back pain in pregnant women. Acta Obstet Gynecol Scand Mar 1999;78(3):180-185.

4 Field, T et al. J Pregnant women benefit from massage therapy. J Psychosom Obstet Gynaecol. 1999 Mar;20(1)31-8.

5 Diakow, PR et al. Back pain during pregnancy and labor. J Manipulative Physio Ther. Feb 1991;14(2)116-8.

6 Guerreiro da Silva, JB et al. Acupuncture for low back pain in pregnancy. Acupuncture in Medicine. 2004 Jun;22(2):60-7.

Sitting with the legs crossed is something many people do. If you have any back, hip, or knee problems, it may be best for you to try to break this habit and there’s a few reasons why.

1. It creates an imbalance in the pelvis. When you sit with let’s say the right leg crossed over the left, the right side of the pelvis shifts higher than the left. This creates an uneven alignment throughout the lower spine that translates all the way up to the neck. Anatomical imbalances such as these, particularly when prolonged or sustained, can eventually contribute to dysfunctional posture and pain. Sciatica, sacroiliac instability, and low back pain can be caused or exacerbated by this way of sitting.

2. You probably always cross the same leg on top. The majority of people always cross the same leg on top. It’s a habit, the body gets used to it, and the muscles around the hips, knees, and pelvis change in response to this. This also applies to when you sit cross legged on the floor. If you sit down on the floor without thinking about it, then change which leg is positioned in front, it will most likely be a very obvious difference in how comfortable you are. (I always have students in my yoga classes switch which leg is in front to create better balance in the body.)

3. Crossing the legs places strain on the knees. When the leg that’s crossed is positioned with the top knee out to the side and the ankle resting on the opposite knee, the ligaments on the knee can be stressed. There can be compression of the cartilage within the knee which can also be damaging over time.

4. Circulation is compromised when the legs are crossed. The compression that occurs from the legs being crossed makes it more difficult for the veins to return blood from the legs back to the heart. This is why the legs can sometimes be felt to “fall asleep” if the legs are crossed for prolonged periods.This can be problematic especially for individuals with vascular disease, diabetes, and other problems with circulation.

So if you find that you cross your legs and you’re having a hard time breaking the habit, be aware of your body and switch which way you cross periodically to restore symmetry and reduce your likelihood of pain or injury.