BACK INJURY BASICS

Michael J. Mullin, ATC, PTA

Clinical Athletic Trainer Orthopaedic Athletic Performance Therapy Portland, ME

ANATOMY
Bones (26)
Vertebrae
Cervical (7)

Sacrum
-3 fused bones

Thoracic (12) Lumbar (5)

Coccyx
-tailbone

Soft Tissue
Muscle / tendon
movers stabilizers

Ligament
anterior longitudinal (hyperextension) posterior longitudinal

Soft Tissue
Nerves
motor vs. sensory brachial plexus, sciatic (sacral plexus)

Fascia
superficial--just below the skin, permits free movement deep--which envelopes, invests, and separates muscles a. irregular sheaths of collagen and elastin fibers b. continuous with each other c. separates muscles and structures while allowing independent function & absorbing shock

Intervertebral discs
Gelatinous structures separating the vertebral bodies
foremost function is to separate and allow for movement between the vertebral bodies well-designed to withstand compression poorly designed to withstand rotation or excessive bending

POSTURE
Alignment: natural spinal curves designed for shock absorption and to withstand compression

POSTURE
Ideal (plumb line) vs. reality Kyphosis (Hunchback) Lordosis (gymnast) Flat-back (nerd) Sway-back (The Matrix) Scoliosis

SCOLIOSIS
lateral curvature (S- or C-curve) most often corrects to midline can be functional or structural can be lifelong or adult onset if a contributing factor to back pain, pain is most often present at the apex of the curve adult onset can be due to chronic laxity (looseness) of the ligaments, osteoporosis, previous injury or surgery

Effect on musculature
Standing regular standing posture vs. habitual patterns Sitting affected by position, chair, activity while sitting, time spent sitting Activity how much movement, kind of motion, repetition

Prevention of injury or reducing stress following injury

Work posture and modification
seated posture (head, arm pelvis and foot position) computer, telephone, repetitive positioning standing postureweight shifting, locked joint positions lifting, carrying, moving, repetitive positioning postural cuesuse pain, tightness or recognition of your back as a reminder get up and move around regularly!!

Other considerations
Travel posture and modification Day-to-day activities Day-to-day activities Getting adequate sleep Psychosocial considerations

BACK PAIN
RISK FACTORS
Poor posture Poor conditioning Weakness Stiffness Faulty body mechanics Poor work, sleep, or eating habits Smoking Psychosocial--bad attitude, stress, emotional Other pathology (i.e. fibromyalgia, chronic fatigue or pain syndrome, osteoporosis)

Everyones favorite treatment works short term

WARNING SIGNS
Numbness into any limb (especially persistent) Radicular symptoms (i.e. numbness/tingling down an extremity) Persistent headaches (especially following traumatic neck injury) Transient weakness Off-balance (persistently) Central, localized persistent back pain / especially if consistently reproduced with one specific movement Persistent resting pain Unexpected weight loss associated with back pain

INITIAL TREATMENT
Bedrest vs. measured activity Medications NSAIDS, acetominophen, ibuprofen Modalities ice (15-20 min.) regularly heat--when stiff during day analgesic balms Physical therapy / exercise / pool therapy Education

INITIAL TREATMENT
Traction (?) Manipulation (?) Alternative treatments acupuncture / acupressure massage / craniosacral / myofascial release Pilates psychological / psychosomatic Supplements glucosamine and chondroitin sulfate

We all want that magic pill

Exercise and back pain

Functional neutral positioning
Optimal position or range within which the spine functions most efficiently Position where the spine is least symptomatic Variable from patient to patient Changes as symptoms and pathology changes Imperative for patient to master and understand to successfully learn and utilize functional training NEEDS TO BE MAINTAINED DURING ALL MOVEMENTS (i.e. activities of daily living, working out, back exercises)

Isolation of the deep abdominal muscles (transverse abdominus)

Designed for long-term use versus more superficial muscles (Type I vs. Type II muscle fibers) Acts as the main active stabilizer for spine and pelvis control Recruited by actively drawing in on abdominals like you are trying to pull your bellybutton up between your shoulder blades NOT a pelvic tilt Causes a co-contraction of the deep back stabilizers (multifidus)
NEEDS TO BE MAINTAINED DURING ALL MOVEMENTS

FLEXIBILITY
Joint / structural restrictions
hyper- or hypomobility of the sacrum or any of the vertebrae structural vs. functional

Soft tissue tightness

hamstrings, hip flexors, hip rotators, lateral stabilizers intercostals between the ribs decreased shoulder motion

Stretching
static stretching vs. active or active-isolated

General considerations
All exercise must be PAIN-FREE Start slowly and gradually increase as tolerated Exercises should be performed evenly for the abdominals and back muscles Weight bearing exercises need to be performed in order to increase the strength of the base of support Some form of controlled cardiovascular exercise needs to be incorporated

TIPS & TRICKS

When in doubt, breathe out Your back is your alarm clock Chuck the wallet from the pocket Come on baby, dont do the twist Youve seen the pictures and heard it before, bend at the knees Its all in the abds. . .

MOST COMMON CAUSES OF POOR POSTURE AND THEIR SOLUTIONS

Forgetfulness--Lets face it, the main reason most people cannot maintain good posture is forgetfulness. Unless someone is in pain and is able to use that as their reminder, people just do not think of it often enough.

SOLUTION:
Use a Reminder--Pick something that you think of regularly during the day--your spouse, your children, driving, every time the phone rings--and use that as your alarm clock to remind yourself to correct your posture. The more often good posture is practiced, the easier it is to maintain, the more natural and comfortable it feels--and it makes up for the times which you forget.

CAUSE:
Lack of Understanding--Most people do not truly have a thorough understanding of proper postural positioning. They view it as a military-style posture by thrusting their shoulders back, or straighten up through their mid-back and forget the head and neck.

SOLUTION:
Use Your Pelvis and Abdominals-There are two keys to proper posture--enough mobility through the pelvis, and a good idea of what to tighten through the abdominals. Start by sitting up straight in a chair with your feet planted or lying on your back on the floor with your knees bent. Place your hands on your hips so you can monitor hip motion, then start by tilting your hips forward like you are arching your back, and hold for 3 seconds. Then tilt them back and up by pulling up on your deep abdominal muscles and hold for 3 seconds. Do this 5 or 10 times, then find what is roughly midway between both stopping points. This is where you want to be. If you think about your deepest abdominal muscles holding this position, you will not only find it easier to maintain, but an almost automatic tension reliever.

CAUSE:
Work--Whether the job is at a desk, performing manual labor, traveling long distances, or performing surgery, it all takes its toll on our bodies. We have a tendency to tighten up into positions which we are regularly in and this eventually causes a breakdown somewhere along that chain.

SOLUTION:
Change Your Ergonomics--Both physically and structurally. Physically by modifying your work environment to be more movement friendly, and structurally by the way the tasks are performed. Whatever the job is that you do, you need to think of putting yourself in the optimal position to perform the task. Desk and keyboard height, repetitious tasks, and heavy lifting all need to be evaluated to make sure that the work station and environment do not predispose or exacerbate injuries.

CAUSE:
Deconditioned--With todays hectic world and pace, people have been finding it increasingly difficult to maintain some form of regular exercise. This not only prevents the release of the much needed stress-relieving endorphins, but it also contributes to weakening of the muscles, bones and joints of the body and reducing the amount of good synovial fluid into the intervertebral discs.

SOLUTION:
Exercise--You are only as good in your personal and professional life as you feel. When the body does not get some form of regular exercise or activity, things just do not work as well. You never let your car go much more then a few days without running it, so why should you think that the body is any different. Any combination of home exercise programs, pool workouts, outdoor exercise, gym routines, yoga, or Pilates will work. Just make it consistent.

CAUSE:
Anatomical--Some of us are born with, develop, or acquire physical conditions which make what would be considered good posture extremely difficult. Mother Nature can be cruel sometimes.

SOLUTION:
TreatmentFirst, dont blame it on your mom. There are a number of different quality practitioners such as physical therapists, physiatrists, and chiropractors, which can help to treat individual conditions. If the system is not functioning properly, forcing it will not help. The longer people wait to seek treatment or do not maintain their recommended routine, then the worse the condition will get.