Rehabilitation for a Healthy Back, By: Brad Walker

This month's issue of the Stretching & Sports Injury Newsletter comes from a well-respected web site called, Spine-Health.com. Spine-Health has been developed by a multi-specialty group of medical professionals, and their goal is to provide you with a comprehensive, highly informative and useful resource for understanding, preventing, and seeking appropriate treatment for back & neck pain and related conditions.

If back pain has caused you any problems, either now or in the past, I highly recommend you visit Spine-Health. Their extensive range of back care information and articles is second to none.

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People who suffer from lower back pain are often encouraged to participate in their own recovery, but they are seldom given the knowledge and tools needed to accomplish this. This discussion will help you acquire a basic understanding of the reasons for lower back pain, and take charge of your own health by taking the appropriate steps to rehabilitate your back.

Of course, getting better is only the beginning, since further episodes of back pain are quite common as time passes. Fortunately, you can improve your chances of avoiding recurrences by rehabilitating your back, whether you are experiencing your first bout with low back pain or have had extensive treatments or even surgery.

Causes of back pain
There are several structures in the back that can cause and/or contribute to low back pain.

Although the intervertebral disc is a remarkably versatile and strong structure, essentially acting as a shock absorber as we go about our activities, sometimes the disc fails when there is a sudden, unexpected force (such as a fall, lifting or other trauma). And when the disc does get injured it cannot repair itself very well, which is one of the major reasons recurrent back pain is so common.

Making matters worse, the pain often prevents us from getting enough exercise, which adversely affects disc nutrition. Nutrition for the disc is achieved when physical activities cause the disc to swell up with water and then squeeze it out - much like a sponge. When pain affects our physical activity, the injured disc is deprived of its nutrition and begins to degenerate.

Activity is also needed to maintain the exchange of fluids in spinal structures and reduce swelling that naturally occurs in the tissues surrounding an injured disc. This swelling can further irritate nerves that are already affected by herniated disc material.

The muscles, ligaments and tendons in the back are also very important in maintaining proper spinal balance and strength. With decreased activity, the connective fibres of ligaments and tendons can begin to adhere to each other and lose resilience and may tear when sudden overload occurs. Unlike discs or connective tissue, however, when muscles are injured, they can quickly repair themselves.

However, muscles contribute to chronic back pain. When nerves are cut or pinched, the muscles they control cannot work, as sometimes happens when a herniated disc presses on a nerve. Also, since muscles are in constant communication with the central nervous system, anger or anxiety can tense the muscles and cause muscle spasms. Ongoing tension inhibits normal muscle function and leads to muscle wasting and further stability problems, which in turn can lead to chronic lower back pain.

Acute vs. chronic back pain
It's important to note that acute pain is different from chronic pain. We have all experienced acute pain from a sudden soft tissue injury, such as a sprained ankle, or even just a simple paper cut. The pain is immediate, but gradually resolves as the injured part heals.

Unlike acute pain, chronic pain comprises a constant low level of stimulation to the nervous system that eventually becomes a pattern. It may even persist as a “neural memory” after the initial source of irritation has resolved. The adaptation of our nervous system to this chronic stimulation creates an environment in which events that previously caused no pain become a source of pain. Pain may even progress to uninjured areas.

Emotional distress and certain medications can exacerbate this phenomenon. An effective solution is to distract the nervous system by means of active exercise in a controlled, non-destructive manner. This also helps to create the physiological conditions that allow the injured structures to heal.

Rehabilitation exercises
One of the keys to recovering from an episode of back pain or surgery, and to help avoid future recurrences of back pain, is to undergo proper rehabilitation in terms of stretching, strengthening and aerobic conditioning of the back and body. This requires a basic understanding of the types of muscles that need to be conditioned.

There are three types of muscles that support the spine:

• Extensors (back and gluteal muscles): used to straighten the back (stand), lift and extend, and move the thighs out away from the body.

• Flexors (abdominal and iliopsoas muscles): used to bend and support the spine from the front, they also control the arch of the lumbar (lower) spine and flex and move the thigh in toward the body.

• Obliques or Rotators (side muscles): used to stabilize the spine when upright, they rotate the spine and help maintain proper posture and spinal curvature.

While some of these muscles are used in everyday life, most do not get adequate exercise from daily activities and tend to weaken with age unless they are specifically exercised.

For all forms of exercise, it is advisable to see a trained and licensed physical therapist, occupational therapist, chiropractic physician or physical medicine and rehabilitation physician (also called a physiatrist). Depending on your specific diagnosis and level of pain, the rehabilitation program will be very different, and these specialists are trained to develop an appropriate rehabilitation program and provide instruction on correct form and technique.

Stretching
Any form of inactivity, especially where an injured back is involved, is usually associated with some progressive stiffness. Therefore, it is necessary to push the range of motion as far as can be tolerated (in a controlled manner). Patients with chronic pain may find it takes weeks or months of stretching to mobilize the spine and soft tissues, but will find that the increase in motion provides meaningful and sustained relief of their back pain.

Stretching exercises should focus on achieving flexibility and elasticity in the disc, muscles, ligaments, and tendons. Additionally, it is important to activate and strengthen muscles not directly involved with the injured area, such as the arms and legs. For example, the hamstring muscles play a role in lower back pain, as it is clear that hamstring tightness limits motion in the pelvis and can place it in a position that increases stress across the low back.

Specialized equipment is available that helps repetitions to be done in the same manner so that progress can be identified and the level of exercise regulated.

Stretching is one of the most under-utilized techniques for improving athletic performance, preventing sports injury and properly rehabilitating sprain and strain injury. Don't make the mistake of thinking that something as simple as stretching won't be effective.

For an easy-to-use, quick reference guide of more than 100 clear photographs of every possible stretch, for every major muscle group in your body, get a copy of The Stretching Handbook. You'll also learn the benefits of flexibility; the rules for safe stretching; and how to stretch properly.

Strengthening
It is thought that re-injury is less likely to occur if back strengthening is accomplished than if mere pain relief is achieved with just stretching. An episode of back pain that lasts for more than two weeks should be treated with proper strengthening exercises to prevent a recurring cycle of pain and weakness.

There are two primary forms of exercise for strengthening and/or pain relief that tend to be used for specific conditions. When appropriate, the two forms of physical therapy may also be combined.

• McKenzie exercises, in general focuses on extending the spine to reduce pain generated from the disc space. Theoretically, extension may also help reduce a herniated disc and reduce pressure on a nerve root. For patients who are suffering from leg pain due to a herniated disc (e.g. sciatica), extending the spine may help reduce the leg pain by "centralizing" the pain (moving the pain from the leg to the lower back). For most people, back pain is usually more tolerable than leg pain. Sometimes, based on the structured evaluation, flexion exercises are appropriate.

• Lumbar stabilization exercises focus on finding the patient's "neutral" spine, or the position that allows the patient to feel most comfortable. The back muscles are then exercised to teach the spine how to stay in this position. Performed on an ongoing basis, these exercises can help keep the back strong and well positioned. Special attention is paid to the extensor muscles of the lower back with resistance exercises.

Additionally, a strengthening program that involves progressive loading and unloading of the lumbar spine by means of flexion/extension exercises can reduce pain and increase the perception of improved back strength. This training, called facilitation, is best accomplished when the muscles to be facilitated are isolated in some way so that other muscles cannot take over the job. Often specific equipment is required to achieve that goal.

Low-impact aerobic conditioning
Finally, conditioning through low-impact aerobic exercise is very important for both rehabilitation and maintenance of the lower back. Aerobically fit patients will have fewer episodes of low back pain, and will experience less pain when an episode occurs. Well-conditioned patients are also more likely to maintain their regular routine, whereas patients with chronic low back pain who do not work on aerobic conditioning are likely to gradually lose their ability to perform everyday activities.

Examples of low impact aerobic exercises that many people with back pain can tolerate include:

• Water therapy (also called pool therapy or hydrotherapy). For people with a great deal of pain, water therapy provides a gentle form of conditioning as the water alleviates gravity and provides buoyancy as well as mild resistance.

• Walking. Many people think that walking as part of their daily routine (e.g. at work or while shopping) is enough. However, this stop-and-start type of walking is not adequate for aerobic conditioning. Instead, continuous walking at a sustained pace for a minimum of twenty to thirty minutes is required to provide aerobic conditioning.

• Stationary biking. Riding a stationary bicycle provides aerobic conditioning with minimal impact on the spine. This is also a good exercise option for people who are more comfortable positioned leaning forward.

Depending on your injury and exercise preferences, you may prefer a different form of exercise. It may be helpful to discuss your options with your physical therapist, or physician to identify an appropriate form of aerobic exercise for you and incorporate it into your exercise routine.

Guidelines for successful recovery
In addition to stretching, strengthening and aerobic exercises, there are several basic guidelines that can help you in your healing and rehabilitation process. These guidelines include:

Manage anxiety
Controlling anxiety and fear of re-injury is very important to regain normal muscle function. The basis for these psychological reactions to low back pain lies in the central nervous system, which responds to pain by instructing the muscles near the affected part to protect against further injury. Only appropriate physical training that specifically tells the muscles to improve their function can overcome this neurological barrier to normal muscle function.

Eat properly
The healing process can be aided with appropriate nutrition, which includes adequate calorie intake in a balanced manner. If all calories consumed are in the form of sugars (such as breads, pasta, and sweets), any calories not immediately needed for energy are converted into fat. You don't need extra weight while you are in the healing process. Your diet should include adequate protein as a source of the building blocks of soft tissue healing. Additionally, fresh fruit and vegetables supply the vitamins and trace elements necessary for effective healing. A vitamin supplement may also be helpful.

Get adequate sleep
One of the best ways to encourage sleep is to induce physical weariness through active exercise. Chronic inactivity does not create a need for the deep sleep that is so helpful for physical and emotional healing. Clearly, stimulants such as caffeine or nicotine should be avoided at bedtime. Smoking should also be avoided because it diminishes the available blood supply and makes the nervous system more sensitive.

Control medication use
While medications are often important for pain relief, one should also be careful about the use of medications. For example, use of narcotic medications and muscle relaxants over time may cause depression and should be used as little as possible. Also, while anti-inflammatory medications may provide pain relief, there is no evidence that they do anything to speed the process of healing. The use of heat or cold, or liniment or massage, as a mechanism for pain control is a very safe and positive alternative for pain management.

Exercise properly
Exercise in a controlled, gradual, and progressive manner is the only way we can tell our body to heal. Injections and medications can provide pain relief but cannot stimulate the healing process. If a pain problem has persisted for many weeks, the body is demonstrating that there are barriers to the healing process that need to be eliminated. The natural stimulus for the healing process is active exercise. Active exercise means we use our nervous system to tell the muscles what to do, and includes dedication to an appropriate, comprehensive exercise and rehabilitation program.

Finally, an important guideline is to seek the assistance of an appropriately trained and licensed health professional for your rehabilitation. And it’s always important to see a physician if your lower back pain lasts for more than a few weeks or a month, or if you have any symptoms that cause you concern, as the continued pain and/or symptoms may signify a serious medical condition.

Ultimately, participating in developing and maintaining an active rehabilitation program for back pain should help you heal faster and have fewer recurrences of pain.