Nearly everyone has had back pain at some time or other. In my clinical practice, the majority of patients showed up with back pain. I’ve had it too! There have been times when I’ve done things I knew were bad for me, but time pressures (and being plain stubborn!) overrode my common sense and medical knowledge. I’ve just returned from four months in Tasmania, where Bob and I were trying to tidy up some bush properties. We felled some fairly large trees, and cleared a lot of deadfall that had built up over the past three years. It was really hard work! From time to time I realized my back was in trouble, and I needed to do more preventative stretches.
If you’re suffering low back pain, the post Treat your postural pain now might be helpful to read first. But if you’re past the point of postural pain and you now have pain in other positions (not just when your posture is poor), you also need to read this post.
Let’s take a closer look at the spine:
The vertebrae (bones of the spine) are stacked one above the other, with discs in between to provide some shock absorption.
In our younger years the discs are flexible and thick. In each segment of the spine there are three main areas of weight bearing – the disc at the front (between the bodies of the vertebrae) and the two facet joints bracing the spine at the back. This system forms a tripod.
Bending forward (or sitting) increases the pressure within the discs and decreases pressure on the facet joints. Bending backwards (as in standing, walking, and lying on your stomach) decreases pressure within the disc but increases pressure on the facet joints:
Disc pressure while bending forward/sitting Reduced disc pressure while bending backward
Little cracks form in the rings of the disc as years go by, probably because we bend the spine more than we should, putting pressure on the disc. The gel of the nucleus, in the centre of the disc, can force its way like cold toothpaste down these cracks, gradually lengthening them. Slowly, over the period of months or years, the gel works its way through the cracks toward the outside layer of the disc. Finally, the disc material can cause the outer layer of the disc to bulge out, which is very painful. But as long as the disc wall is intact, you can change the pressure within the disc simply by changing the position of your spine. This diagram shows a bulge which progressively gets worse, until the pressure actually breaks the outer wall of the disc:
Imagine a balloon between your palms, which you can squeeze one way or the other. As long as the rubber wall of the balloon is intact, you have control over the air within it. But as soon as you pop the balloon, you have no further control.
You are especially vulnerable to back injury in the mornings, when the discs are swollen with fluid after resting all night and are vulnerable to excess pressure. (Did you know that you’re taller in the morning than you normally are, due to increased disc height at every level in the spine? It’s true!)
Most early spinal pain issues seem to respond well to self-treatment. Sometimes pain can be due to muscle spasm, although this is not common – usually muscle spasm is a reaction to pain from another source. Discs tend to be the first line of defence in the spine, and can bulge or ‘derange’ now and then, causing pain as the bulge presses on sensitive tissues such as ligaments and/or nerves. The majority of cases settle spontaneously but, with each episode of pain, the damage inside the disc(s) tends to increase. As the damage proceeds, the facet joints also begin to wear. Pain can be due to a combination of factors, from all points of the ‘tripod’.
With age, the discs become flatter and stiffer, having ‘dried out’ somewhat. This means they are less likely to bulge – but because the discs have lost height, more pressure is thrown onto the facet joints, which can cause the cartilage on them to wear too. Osteoarthritis of the spine means wear and tear on these joints. There can be extra callus and ‘lipping’ of the vertebral edges. Here you can see a spine with osteoarthritis:
I didn’t invent the home treatment methods I am about to show you. In the 1980s while I was working in England, I travelled to Switzerland to visit a friend who was living there. She was also a physical therapist and was enthusiastic about a short course she was doing at the time. I had arrived on the last day of the course and was prepared to wait for her, but she insisted I go along too. “The guy taking this course is from New Zealand. Come along – I know he would love to see you!” That was my introduction to Robin McKenzie and his famous self-treatment techniques for the spine.
Robin was a vibrant, funny, practical and effective physiotherapist and teacher. He won many awards around the world for his amazing work. I was hooked immediately. Especially when a Swiss woman, who spoke no English and had been wheeled in on a stretcher, was told to get off the bed after doing a few simple movements. She gingerly complied, walked around the room with an ecstatic look on her face then rushed over and gave Robin a big kiss!
I went on to do two of Robin McKenzie’s courses myself. Most of my patients have responded to these methods, although some have also needed hands-on treatment and other methods.
How can I tell what is causing my pain?
Ask yourself the following questions:
- Did the pain come on as a result of external forces (impact, accident, assault etc) or for no apparent reason? (If there is no apparent reason other than pressures of living, then self-treatment should be able to correct the problem before it gets too serious. If you have osteoporosis (weakened bones) and/or had an accident, fall, assault, sporting injury or any other external force was involved, then I would strongly advise you to see a doctor, who may order an Xray before you begin any form of treatment.)
- Have you had several episodes of pain over many years? Or has the pain gradually been increasing, without any relief? (If several episodes, it could be a disc problem which flares up every so often and settles between episodes. You may be pain-free for months or years between episodes. If pain is gradually increasing without relief, it could be due to arthritis or another condition affecting the facet joints and attached ligaments.)
- Did the pain come on fairly quickly or has it been coming on gradually? (If it came on suddenly it is more likely to be disc related. This is especially the case if you were bending, sitting or lifting at the time or shortly beforehand. Facet joints can also cause a sudden problem, but the picture will become clearer as we proceed with the questions.)
- How long have you had the pain? (If it has come on quickly, you’d expect it to get better faster. If you’ve had it for a long time, it is less likely to get better quickly.)
- Where is the pain? (If it is in the spine or close to it, results should be faster. The further down the leg the pain is, the longer it might take to improve.)
- Is the pain intermittent or constant? (If intermittent, it is more likely to be relieved easily. If the pain is constant, does it change or is it always the same? If the former, you could still gain some benefit; if there’s no change with any position, these methods will probably not work for you.)
- Is the pain worse with forward (bending/curling) movements such as sitting or bending forward? Or is it worse when stretching backward, walking or lying down? (f worse with repeated forward bending, the problem is more likely to lie with the disc, as repeated squeezing of the disc will worsen the bulge. If worse with repeated backward bending, the problem could lie with the facet joints – perhaps an arthritic condition. Not necessarily, though – a large disc bulge can cause pain with repeated backward bending too, if it is being ‘pinched’ by too vigorous a movement. So when testing yourself, go very gently. Only move until the very instant you feel pain or obstruction.)
- Does the pain increase with coughing, sneezing or straining? (If so, it may indicate that a disc is bulging back onto a ligament or nerve, and the extra pressure from the strain increases the bulge.)
- Do you have pain at night or not? And if so, in what position? Does the pain increase when you’re on your back or side, and does it ease or not when you lie on your stomach? (Constant nagging pain during the night when you’re resting may indicate an inflammatory condition. However if the pain is relieved when you increase the low back arch, and increases when your low back is curled up, it is most likely due to a disc problem. If the pain is caused by facet joint problems, it might ease when your back is curled, opening up the joints, and be worse with arching backward, when the joints are compressed.)
- Is the pain central or off to one side? (If central, it should respond more quickly. If the pain is local (in the spine or close to it) there is probably pressure on a central ligament. If the pain runs down into a buttock or leg, there is probably pressure on one of the spinal nerves which supplies the leg.)
- Is your body straight, or are you leaning to one side? (If your body is straight, you should get faster results. If you are leaning away from the side of pain, you should respond faster than if you’re leaning toward the side of pain. It will probably take about twice as long for results in the latter case. Note: A disc bulge can occur above or below the nerve root on that side. If you are leaning to one side, your body is trying to reduce the pressure, and therefore relieve the pain.)
- You are prone to having episodes of ache or pain which settles completely in between episodes.
- Your pain came on suddenly, after bending or sitting, or while trying to lift something (even a light object).
- You have only had the pain a short time.
- Your pain is intermittent, worse with sitting and bending but relieved by resting on your stomach and when walking.
- Your pain is central over the spine itself, or at least not progressing downward past the knee.
Caution: If your pain is constant and no position relieves it or makes it worse, get in touch with a doctor immediately. If you have pain, numbness and/or tingling or weakness which is constant and unaffected by movement, there could be pressure on a nerve as it leaves the spinal column. In this case do NOT attempt to treat yourself, but get medical help.
What can I do for my back pain?
The spine in the low back is heavier and strong and it appears that discs are more responsible for pain in this area, at least in the early stages. In the spine of the neck the facet joints are possibly to blame as much as the discs.
The first thing to do is to avoid further harm, so don’t persist with the movements or positions you know will aggravate the pain. Nine times out of ten these will be flexion, or bent/curled, positions (sitting and bending).
In the simplest situation, the pain is central in the low back or slightly to one side of the spine. The treaatment methods assume that the problem lies within the disc(s), and if you respond well that will verify the assumption.
The gel in the centre of the disc has shifted to produce a bulge against the outer wall of the disc. So you need to gently manipulate the gel, squeezing it back to its normal location by using your position and movements. After all, this injury happened without any external force – it was something YOU did. So you should be able to reverse the forces that brought it on, especially if you catch it early.
Exercise 1: Get yourself into a neutral position as quickly as possible. That means lying on a flat surface on your stomach.
This may be inconvenient, especially if you’re rushing to get to work, in a public place, or travelling somewhere! Do your best to find a private place where you can lie down. I once had back pain while driving. I pulled into a service station (gas station, for my American friends) and went around the back, where I found an old concrete slab. This was perfect for my self-treatment session. A park or roadside grassed area would do also – nobody pays attention to someone relaxing on the grass under a tree.
Lying on your stomach may be painful at first so, if it is, try tucking a pillow (or even your lumbar roll) under your stomach.
Breathe regularly and try to relax. It may take a few minutes but the pain should finally ease. Slip the pillow out, if you had one, and relax again, focussing on your breathing until the arch in your back is restored. Imagine the gel sliding down the crack it is in, back toward the central bowl within the disc where it belongs.
Exercise 2: Has the pain eased, after doing exercise 1? If so, now we need to gently but persistently stretch the lumbar spine backward (‘extend’) to increase the forward pressure on the gel of the disc. Prop yourself up on your forearms, in a position we call the ‘sphinx’ position. Stay here only for a minute or two. Too long and your facet joints may begin to ache. We don’t want to stir up one problem while fixing another!
Breathe in and out regularly, trying to relax the muscles around your trunk, to allow the spine to sag. If you felt pain when first adopting this position, it should reduce as you relax. If not, go back to exercise 1 and continue with it for a bit longer.
Exercise 3: Now we need to apply a little more pressure. Place your hands to either side of your shoulders, as if to do a push-up. Gently push down with your hands, while you straighten your elbows, then lower yourself flat again.
Don’t hold your breath or force through pain. If you feel pain at any point, come back to the starting position and try again. You may not be able to go all the way up the first time or two, but as long as you aren’t pushing through pain you will be safe.
When you can get all the way up and ‘lock’ your elbows, breathe out and let your lower spine continue to sag. Then relax and lie on your stomach again.
Say to yourself, “Pressure on…pressure off…pressure on…pressure off…” as you perform this movement, smoothly and slowly.
This short video clip will show you how to do the exercise correctly.
After doing ten of these stretches, relax on your stomach for a few more minutes, breathing rhythmically, before you stand up.
To get up from the floor, roll to the side then work yourself up to your hands and knees, (making sure you maintain the arch in your low back). ‘Walk’ your hands up to the armrest of a heavy armchair or other large piece of furniture, and use it to help yourself to your feet.
Perform this series of ‘exercises’ every hour or so throughout the first day. Ideally you should have complete pain relief from the first session onwards. If it helps, it’s ‘more of the same’ for the next five days, although you can do the exercise sessions less often as the days roll by. Robin McKenzie tells us that two-hourly is a good system and indeed it seems to be.
Is the pain still on the side, after doing exercise 3, or has it moved into the centre? If the pain is not responding to Exercise 3 as described, try doing it with a sideways shift, moving the hips a few inches away from the side of your pain. Watch this short video clip.
If your pain is still to the side, or has not been helped by doing exercise 3, there are two more activities that might help shift it. Exercise 3 won’t help if the bulge is too far sideways – first you need to shift it centrally. First try ‘side gliding in standing’. You may also try ‘flexion in rotation’. Either or both of these exercises may bring the disc bulge toward the ‘door’ so it may be squeezed forward by exercise 3 (extension in lying).
I expect older patients to manage fewer sessions, because their level of mobility is usually less and they often have other problems (such as arthritic shoulders and hands) which may make it difficult to do the push-ups. Sometimes we have to modify the stretches, by using only exercises 1 and 2, and substituting exercise 4 (extension-in-standing) for exercise 3 (extension-in-lying):
Exercise 4: Extension in Standing.
Here is a short video clip which demonstrates how best to do this exercise.
Do not relax the arch in your low back for five days! That doesn’t mean keeping a strain in the arch; it just means supporting it, not slouching. Use a lumbar support (a foam roll, or a shaped foam cushion) whenever you sit, and spend very little time sitting, anyway. If you want to rest a while, lie down rather than sit. Walking is very good, as long as there is no pain with it, but apart from the exercises described here, I don’t advise any other active exercises or stretches during the first five days of recovery. Using your trunk muscles or curling (flexing) the low back will increase the pressure in the abdomen and compress the disc – which you really shouldn’t do during the healing process.
Some activities are bad news for the low back arch: for example sitting in a bath, bending over to pull on socks or shoes, and sitting on the floor, cause the arch to flatten out. Think about every position or activity you do and decide if it is safe or not. If you feel pain increasing in any position, chances are that position is NOT good for you!
It takes around five days for the injured area to seal, heal, and be ready for stretching out. Be patient and give it that time, even if you feel like stretching it earlier. Too many people suffer discouraging relapses because they thought they were better. Please don’t test your back out earlier than the 5 days! Even if it feels much better, or just a bit stiff, please don’t try to stretch it earlier (by bending, or by sitting without support). Whenever there is an injury, there will be a scar forming, even if you can’t see it.
Imagine your scar as a piece of cotton wool. It can easily be pulled apart. As scar tissue forms, fibres are laid down haphazardly, just like cotton wool – very fragile. The second part of the treatment (the recovery phase) deals with this – by gently stressing the tissue so that the scar fibres line up along the lines of stress. We need to make sure the scar is strong enough to handle bending forward. It takes only a few days. Until the scar is ready for stressing, please don’t do it! If it gives way you could be back to square one.
Plan on five full days WITHOUT stressing the scar tissue. Then plan on another 2 or 3 days stretching it out in a controlled manner, working up to full range of movement.
The next post will deal with the recovery phase – what to do after the five days it takes to heal your injury!
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