The View from Sports Center

How Much Exercise is Enough for Lower Back Pain?

Some people with lower back pain (and some clinicians as well) view physical therapy as a treatment. It's something you get for a period of time until your symptoms retreat slithering away into the background. At that point, you think you're well.

Maybe you are but for many people short term therapy creates an illusion of sturdiness; a veneer the thickness of an eggshell. You just think you're good to go.

The solution for long term results and a veneer that's closer to hardiplank than an eggshell is exercise. You have to exercise the rest of your life. Exercise is no longer an option. It's a necessity.

But, how much is enough? Once, twice, three times per week? And, how do you find the time for it?

Researchers from the University of Alberta studied this very issue and discovered that people with chronically sore lower backs had 28% less pain and 36% less disability when they exercised four days per week as compared to two or even three days. People who exercised two or three days week also improved but not as much as the four days per week group.

How do you find the time?

You don't. You make the time.

That's the truth. No one ever just finds time lying around in a corner or under a mat or beneath a chair. You're too busy. You make time. And, to do this, something must die.

You have 24 hours in a day and you should spend 7 to 8 hours sleeping. So, you're down to 16 hours. Most people work 8; now you have 8 hours. And you probably have some commute time somewhere in there too so let's say 2 hours total commuting. Now, you have 6 hours. And, you spend maybe 30 to 45 minutes in the morning getting ready so let's be generous and call that an hour. Now, you have 5 hours. Spend 90 minutes at dinner - that leaves you with 3.5 hours. Spend an hour or two with your kids (if you have them and they're young enough they still want to be around you :-), now you have about an hour and a half. Now, here is where the dying occurs.

What you may want to do is read, surf the Internet, watch T.V. - something. But, what you need to do is exercise for 30 minutes. I can already hear the howls. "There's no way I can do that!" Yeah, there is. The time is there. You have to take out a sword and strike down dead the thing that's in your way - like T.V.

Now, before someone gets too upset, I know there are situations where you really don't have the time. Maybe you're a single parent with three kids and you work two jobs or maybe you're working your way out of debt and can get, at best, 6 hours of sleep a night. You're an outlier though. You are not the bell curve. You get a pass.   

Otherwise, I'll bet you can make the time. Remember, four days a week is best; two helps. Start with two days. Just two days a week. The solution for most people is to insert exercise (and I prefer the term "training" but that's another argument) at the beginning or middle of their day. Go to bed two nights per week, thirty minutes earlier and get up thirty minutes earlier in the morning. Get a routine together you can do at home and do it. It will take you at least a month (and the research on how long it takes to form a new habit is sketchy - some reports are one month and some reports suggest three months) until you quit grumbling and fighting the urge to go back to bed. You have to be disciplined - a disciple of your self.

And, if you're not sure where your time goes, get this free report to help you figure it out.

DK

Is the Core Craze the Crux of the Problem?

Reader Renee points us to an article in the NY Times about the dangers and pitfalls of "core" strengthening. It's worth reading as are the comments.

I agree with most everything in the article. The transverse abdominis, while important, is not the only muscle you need to be concerned about and that hollowing the stomach by aggressively sucking it in may do more harm than good by de-stabilizing the supporting structures. Sit-ups are a poor choice for most people carrying far more risk than necessary and that goes for back extensions over the edge of a stool or a Roman Chair too.

My disagreement in avoiding using isolating techniques to activate the transverse addominis is that the stabilizing muscles, multifidus and rotatores, are inhibited following a back injury and since these muscles are not under your volitional control, you must find another way to jump start them. The transverse abdominis is the jump start mechanism. Once you learn how to contract the transverse abdominis (and this is done not sucking in the stomach but rather bracing the mid-section as if you're about to get punched in the stomach), which by the way needs only a mild contraction to turn on the multifidus, you can then move on to more functional drills incorporating the tension from the transverse abdominis.

Of course, there's no strong link between a "weak core" and lower back pain but there is evidence that suggests people with chronic lower back pain tend to have an atrophied multifidus muscle and we know that atrophied muscles are weak muscles.

Hides, J. A., C. A. Richardson, et al. (1996). "Multifidus muscle recovery is not automatic after resolution of acute, first-episode low back pain." Spine 21(23): 2763-9.
Danneels, L. A., G. G. Vanderstraeten, et al. (2000). "CT imaging of trunk muscles in chronic low back pain patients and healthy control subjects." European Spine Journal 9(4): 266-72.

Back Pain and Giving Up

Eighty percent of people will have low back pain in their lifetime bad enough to seek medical care. For some, the symptoms fade within six or eight weeks. But, for over half, the pain returns within one year and often becomes a most unwelcome and rather permanent house guest.

And, what type of care do people get? To find out, a group of researchers in North Carolina contacted 5,357 households and found 732 adults with chronic low back pain*. Of the 732 people, 590 had sought medical care. Here's what else they found:

• 31% had taken a muscle relaxant in the last 30 days.
• 60% had taken a narcotic in the last 30 days.
• Greater than 33% had some form of imaging study done (MRI, CT SCAN) in the past year.
• Less than 30% had seen a physical therapist.
• 3% had been in a spine rehabilitation program.
• Levels of depression were high.

Depression is a common finding in people with chronic back pain and is compounded by a feeling of hopelessness about the situation. Chronic back pain carries a very high emotional tax (and, yes, all pain has an emotional tax but back pain seems to be one of the worst types. Nearly, 54% of people are depressed prior to the onset of their pain.). You worry. You wonder if you'll ever feel better or do the things you once loved to do or even come close. Day after day you get caught in a vortex of anxiety and discouragement. Life is grey.

The passive nature of treatment - drugs - for so many people with lower back pain can unintentionally add to the weight of hopelessness. Sometimes the drugs are helpful and needed to get people moving but as this study shows, few of them ever land in a program designed to help get them moving in the right direction. Instead, they take medication and hope until their hope is so thin and frail it cracks. Some fill the cracks with despair; some bitterness; others use resentment. The fix is as fragile as the crack itself.

What do you do? If you like your doctor and trust him or her, ask for a referral. Tell him you need to see someone who can help you get moving again. Some physical therapists and chiropractors and massage therapists focus their work on movement. Other practitioners who can help are trained in Feldenkrais Method or Alexander Technique. Yoga and Pilates can also be quite effective in the hands of a skilled teacher. If you can't get a referral and your state (or your insurance) requires one, switch doctors. Friends, family, colleagues may also be able to suggest someone that can help you.

Just don't quit. Fight. After all, what's the outcome of giving up?

DK

*Carey, T. S., J. K. Freburger, et al. (2009). "A Long Way to Go: Practice Patterns and Evidence in Chronic Low Back Pain Care." Spine 34(7): 718-724

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The Worst Time To Stretch Your Lower Back

 

Question from a Reader: What's a Good Bed for a Bad Back?

Dear Doug,

 

Thanks for your blog and the detailing of your recovery from a herniated disc. I cannot thank you enough for sharing your wisdom, your blogs are very helpful, interesting and informative.

I have a question. Can you point me in the right direction of a bed or mattress that provides adequate support and spinal alignment for someone who has had a lumbar disc injury?

 

Thanks-

Cade

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Cade -

Thank you for your note and I hope if the someone who had surgery was you, that you're recovering steadily and feeling better.

As for beds, there is very little science that supports one bed over another. One study conducted in Spain in 2003 showed that people who slept on a medium-firm mattress had less pain in the morning and during the day than people who slept on a firm mattress*.

There are at least three things to consider when it comes to sleep and back pain. One is the flexibility of your spine. If your spine is relatively inflexible, then during the night the positions your body assumes may place excessive force on the soft tissues and create high strain rates. Anytime you apply load to joints near the end of their available range you run the risk of excessive tissue strain. For example, try placing your hand on a firm surface, palm up, press down until your wrist is fully flexed and then just stay there. You'll get the idea of how stress at the end of range can create pain.

The second thing to consider is how easily your spine fatigues during the day. The culprit for most spine fatigue is sitting, standing, or being too still for too long. Healthy joints can withstand substantial loads and still maintain tissue homeostasis. But, weakened joints, from injury, disuse, surgery, disease, are more easily overloaded although you may not experience symptoms from the overload at the time of the overload since it can take up to 24 hours for post-traumatic cytokine to be produced (cytokines are proteins that help regulate inflammatory processes). So, for example, if you sit for a few more hours than usual one day, you may find your self in bed with lower back pain that night or the next morning even though you had little to no pain during the sitting event.

The third thing to consider is how well you support your legs and arms in the sleeping position (assuming you sleep on your side). When you sleep on your side, most people find the upper leg and arm will fall forward of the body. This creates torque on the spine and over the course of a few hours can strain tissue. I usually suggest a firm, large pillow either between the legs or under the upper leg (if you prefer the leg to be in front of your body) and a pillow under the upper arm. This will reduce the twisting effect, at least for some time, and make sleeping more comfortable.

One last thought before I make specific suggestions on beds, there is a new device that supports the spine called the Klass Vaki KBS200 that is supposed to hug your spine and support it during sleep. It has been studied and shown to reduce muscle activity and pain. I've not tried it but am planning on testing it. I'll let you know what happens and my opinions on it once I have used it.

So, my suggestions: Tempur-Pedic or Select Comfort Sleep Number. Here's why. The Tempur-Pedic is a high density foam that will both support your spine and conform to it. Some people just love it. Others feel it is too firm. Most companies that sell the Tempur-Pedic will allow you to return it within a certain time frame if you don't like it.

The Sleep Number is an air-based system that allows you to determine the degree of firmness that seems best for you. I think having some control over the firmness is helpful physically and there is a subtle mental boost as well.

Sleep well.

DK

*Kovacs, F. M., V. Abraira, et al. (2003). "Effect of firmness of mattress on chronic non-specific low-back pain: randomised, double-blind, controlled, multicentre trial." Lancet 362(9396): 1599-604.

Chronic Neck Pain: Use Your Arms

Your neck doesn't do any heavy lifting. Your neck positions your head in space and serves as an anchor for muscles of the jaw, shoulder, and arm. The other day I was in a gym and saw a guy, probably around 30, bent over a bench, hands supporting him on the bench, with a strap on his head with some weights on the end of it. His face was twisted into something like the Joker as he fought the downward pull of the weight. Maybe if you play college or pro football or fight in the Mixed Martial Arts arena this has a place in your routine although I would argue that there are better and safer ways to strengthen your neck. For the person who has chronic neck pain, don't ever do this drill or anything like it.

If you have joint weakness (so, think of Degenerative Joint Disease, Disc Disease, Disc Herniation) and your neck feels stiff, tight, or aches, usually what you need to do first and likely insert as part of your lifestyle, are joint conditioning drills. The good news is that for the neck all you need is a small beach ball and a little space on the floor. You can read more about how to do this here.

The trapezius muscle is the large muscle that runs from your spine to your shoulder and shoulder blade (scapula). It is often a site of "neck pain" even though it's not actually your neck. People who perform long duration activities, like working on a computer, often develop pain in this area.

People do all sorts of things for this kind of neck pain: massage, Rolfing, ice, heat, neck exercise, and drugs among others. And lots of these things seem to reduce the pain but there's a type of exercise that is sometimes overlooked that has a direct effect on how long and how often you have this sort neck pain.

Your arm is equal to about 5% of your body weight. So, for a 150 lb person, that's 7.5 lbs or 15 lbs for both arms, pulling on your neck. As you sit at a desk typing away, your neck is resisting the downward tug of 15 lbs - a good size bowling ball. You need really good muscle endurance to withstand that day after day.

There have been a few studies that have looked at muscle endurance of the upper shoulder area in people with chronic neck / trapezius pain and the consistent finding is that people with this sort of neck pain have low endurance of the trapezius muscle. In other words, the muscle runs out of gas quickly. When muscles run out of energy, they hurt. Sometimes muscles will cramp, spasm, or just feel tight.

You can make ergonomic adjustments to your work area - get your keyboard monitor at the right height, make sure your sitting posture is correct, etc., - and these things will help but to really feel good both during your work day and after, you'll want to increase the trapezius muscle endurance.

The trapezius muscle has three parts - upper, middle, and lower. It shrugs your shoulder, pulls  your shoulder blade back and also helps rotate the shoulder blade as you lift your arm. A simple exercise to increase the endurance of this muscle is this:

• Get a timer.
• Push start.
• Sit tall on the edge of a chair.
• Pull your shoulder blades back.
• Lift your arms up until they are parallel to the floor.
• Now, bend your elbows 90 degrees (palms facing down).
• Shrug your shoulders just a little.
• Now hold your arms in this position for as long as you can.
  • Stop the timer when you feel you can no longer hold the position or if you have any pain (you may get tired in your shoulders, neck, or both).
• Record the time.
• Take 70% of the time as your training time. So, if you held the position for one minute, use 42 seconds as your training time (60 seconds x .70 - 42 seconds).
• Rest two minutes before performing the exercise.
• Using 42 seconds as your time, repeat the exercise. Do five sets. Rest one minute between sets.
  • After you have done this for a week, re-test.
• Once you're up to three minutes, instead of using a bent elbow position, straighten the elbow and repeat the entire process (test, calculate 70%, train).

As your muscles fatigue, your posture may change slightly. Pay attention to this. When this happens, adjust your posture back to the tall position. If you can't maintain it, stop. Don't be dismayed if you find your test time to be 30 seconds or less. It is what it is. You can change it. Eventually, you'll find three minutes not all that fatiguing which means it's time to do other drills.

Some neck pain is not actually in your neck but in the shoulder muscles. Try working on your shoulder endurance to improve your overall neck performance.

DK

Speed Intervals Question

R

eader Eric asks, " I notice all of your workouts begin and end with a speed interval session.  Is there some training advantage to the second speed interval session at the end?"
Thanks- Eric

Great question. And, there are two parts to my answer. The first one is that I just like it. I like the feeling and especially on days where I've really stressed my muscles. The second one is that with my history of spine disease and injury, I need all the help I can get.

The disc has a poor blood supply even in healthy individuals. The outer third of the annulus has blood vessels but as you move toward the center of the disc, you have less and less direct blood supply. So, the nutrient exchange comes from the subchondral bone from a very fine capillary network woven into it. As you apply and relieve pressure - cycling, walking, elliptical etc. - the bone oozes nutrients and absorbs metabolic waste into and out of the disc through this network (Rajasekaran, S., J. N. Babu, et al. (2004)). Both the outer rim of the annulus and the inner aspect of the disc respond to movement and as your blood pressure and heart rate climb, blood is pumped into those areas.

This dynamic relationship between nutrient exchange and movement is one reason why sitting so much during the day is so detrimental to your spine. One of my teachers liked to say that,"sitting does to the spine what placing a plastic bag over your head does for your breathing."

So, I basically think of speed intervals as "nourishing" my spine and letting it "breathe".

DK

Routine Lumbar Imaging No Help for Low Back Pain

A study published February 7, 2009 in The Lancet concludes that imaging (MRI, CT Scan, X-Ray) has no effect on outcomes for patients with low back pain*.

According to Dr. Roger Chou, of the Oregon Health and Science University, "Patients with low back pain who had radiography, MRI, or CT scans done without a clear indication had no significant improvement in pain or function in the short or long term through 12 months compared with patients who did not have imaging done."

I don't think this is a surprise really. After all, the purpose of these studies is to help diagnose the patient; not treat the patient. It's what happens after the MRI or CT Scan that drives the outcome.

I had an MRI after a skiing accident last year and discovered a large disc herniation. Knowing this, I did certain things to help my self recover. Now, if the MRI had shown a small disc bulge or only degenerative changes, I would have done different things. The presence of pathology must be correlated with the patient's history and other exam findings to arrive at a diagnosis. THEN, you treat based on those findings.

Wouldn't it be more helpful to look at what is done for people with a disc herniation following MRI and figure out why things turn out the way they do?

DK

*Chou R, et al "Imaging strategies for low-back pain: systematic review and meta-analysis" Lancet 2009; 373: 463-72.

Purpose of Lumbar Supports

"Doug,

I’ve been tuning into your blog over the past several months… great information.  After many years of chronic back pain, I’m scheduled to for a discectomy next month.  I’m actually looking forward to getting some relief.  I have a lumbar support that I where sparingly, only during strenuous activity.  What is your take on rigid plate lumbar supports? "

Thanks,

N

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Personally, I find the rigid lumbar supports uncomfortable. During my recovery and rebuilding, I used a System-Loc. It was comfortable and greatly reduced the motion in my spine.

A lumbar support is helpful but, like crutches, the purpose of a support is to help you get out of the support. Something to be aware of - surgeons will sometimes decide, almost on a whim, to take you out of the support. I've had clients who had worn a brace after surgery for several weeks and then one day, the surgeon decides the support is no longer needed. Of course, the spine muscles are completely unprepared for full body weight loads. What works better is a combination of gradual time out of the brace coupled with a rehab program designed to rebuild your core strength and endurance. Then, when you finally get out of the brace, your spine won't be so shocked.

Here's an article I wrote on the brace I used.

I hope your surgery goes well (and consider following that up with rehab to help you get on the right track) and that you feel better soon.

DK

How to Save Your Kid's Back

I've written about this subject before but have something new to add to the list that could dramatically reduce the incidence of back pain in kids.

A Kindle.

For those of you new to the Kindle, Amazon produces it. It's an wireless reading device that can store hundreds of books. You can highlight words, search for words or phrases, bookmark where you left off and buy books right from the device anywhere.

Why not get all of the books a child needs into a Kindle format and take the money saved and buy the child a Kindle? No more monster backpacks. More reading; less back pain.

DK