Back Pain: Causes and Prevention

Scroll Below to Find:  Anatomy of the Back Region  Common Causes of Back Pain/Injuries  Common Pathologies  Back Injury Prevention Workout Program  Result of Questionnaire: Franklin Pierce University Students  Ten Safety Tips When Lifting & Workstation Setup

Anatomy of the Back Region

The human spine is divided into 4 regions: the neck (cervical spine) which consists of 7 vertebrae known as C1-C7, the mid-back (thoracic spine) which consists of 12 vertebrae known as T1-T12, and the low back (lumbar spine) consisting of 5 vertebrae referred to as L1-L5. The final 2 regions of the spine are fused together as one bone consisting of 9 vertebrae. The first 5 vertebrae are referred to as the sacrum S1-S5, and the final 4 vertebrae, referred to as the coccyx, is commonly called the tail bone.

In between each vertebra there are intervertebral discs, which function like pads or shock absorbers for the spine as it moves. Each disc is made up of a tire-like outer band called the annulus fibrosus, and a gel-like inner substance called the nucleus pulposus. Together, the vertebrae and the discs provide a protective canal that contains the spinal cord and spinal nerves. These spinal nerves run down the center of the vertebrae and exit to various parts of the body. The back also contains muscles, ligaments, tendons, and blood vessels attached to the vertebrae or run thought it. Muscles are strands of tissues that act as the source of power for movement. Ligaments are the strong, flexible bands of fibrous tissue that link the bones together, and tendons connect muscles to bones. Image 1 Causes of Back Injuries/Pain

Back pain is a pervasive affliction in our society today, and is among the leading reasons for physician visits. It is the most common reason for the use of pain and alternative medicine in the United States .3 Back injuries will affect four out five people at least once in their lifetime, mainly due to one’s lifestyle choices.4 Only a small amount of back injuries treated in the United States are due to a traumatic event such as a car accident or a direct impact to the spinal column. The most commonly reported cause of back injuries in the United States is from improper repetitive lifting and twisting of the spinal column. A close second is improper body posture in a seated position for long lengths of time at work stations, while traveling in a car, and students especially in their late teen years and early twenties. Another reported characteristic that has been associated with back pain is smoking cigarettes, but the biological mechanism for this result is not fully understood.10 The peak age of one’s first back injury is in their early twenties and the risk of future back injuries increases dramatically as one ages. Most back injuries can be prevented or the severity be reduced by following a structured daily strengthening and stretching program to promote a healthy back.

Common Pathologies of Back Pain

Muscle Strain: Back strains are most common causes of back pain.1 Back strains occur when the muscle fibers are abnormally stretched or torn.

Ligament sprains: A sprain occurs when the ligaments that hold the bones together are abnormally stretched or torn.

Spondylolisthesis: Is a condition describing slippage of a vertebra anteriorly in relation to the vertebra below it. This pathology is typically seen in the lower thoracic region. Image 2 Spondylolytic or Spondylolisthesis: Is a condition that occurs when a vertebrae above slips due to a small fracture at the joint on the back side of spinal column. It is the common cause of low back pain in children and adolescents.

Disc Related Issues: This condition occurs when there is a disruption of the material contained within the disc. This pathology may be caused by trauma or repetitive bending and twisting activities. The pain is usually radicular (pain or numbness traveling down one’s arm or leg) due to this pathology. Image 3

Degenerative Disc Disease:

Osteoarthritis: It is a condition in which disc degeneration and mechanical breakdown of articular cartilage occurs.

Spinal Stenosis: Is a condition in which narrowing of the vertebral canal and or intervertebral foramen occurs. The narrowing results in irritation of nerves/spinal cord and could occur due to many reasons such as tumor or cyst, congenital reasons or osteoarthritis. Image 4 Please Note: before performing any exercise program on this informative webpage you need to be medically cleared by a medical doctor. If at any time during a workout your feeling pains, shortness of breath, or dizziness stop immediately and consult with a medical professional.

This Exercise Program has 4 Main Parts:  Medicine Ball Routine: builds core strength, increases the body’s range of motion, and involves many muscles and joints working together.  Stretching & Flexibility Routine: lengthens tight muscles and improves flexibility  Floor Routine: targets individual muscles of the core  Core Strengthening: develops core strength, stability, and posture Medicine Ball Chops and Rotations

For all exercises use a light medicine ball (1-6 lbs is usually sufficient) or some other type of weighted implement such as a dumbbell. Perform all movements with control. With all exercises be sure to engage the core (tighten abs!).

Medicine Ball Overhead Chops

Start End Technique: Use your legs to initiate the action, perform a whole-body motion. Perform a chop as you lower your body into a squatting position. While performing the chop make sure it is one fluid motion, not broken up into steps.

Perform: 10 to 20 continuous reps

Good form- neutral spine Good form- proper use of lower body Incorrect- too much use of lower back Incorrect- lower body not used enough

Medicine Ball Full Twists (Trunk Rotations)

Technique: Rotate entire body as a unit. The hips and upper body are moving at the same time. Use the feet to pivot from one side to the other. Perform: 20 total reps (10 each direction) Medicine Ball Diagonal Chops

Technique: With ball overhead or at shoulder height, perform a chopping motion across the body. Finish with the ball past the knee; perform a reverse chop back to the starting position. Be sure to use the hips and legs to pivot; perform with controlled movements. Perform: 10 reps on one side of the body then perform 10 reps on the opposite side.

Medicine Ball Full Circles

Technique: With this exercise you are performing a circular motion. With the arms extended bend at the trunk and the knees to work as a unit. Your body should feel fluid and relaxed while maintaining a tight core. Perform: 10 reps rotating to the Right, then 10 reps rotating to the Left Stretching and Flexibility Exercises

Active Hamstring Stretch

(a) Back of thight (b) (c)

Muscle used: The hamstrings are a muscle group that often contributes to back pain and stiffness. This exercise is an active stretch. Technique: grasp the underside of the thigh just above the back of the knee; then pull your thigh towards your chest. (a) Actively straighten the leg and hold for 2-3 seconds. (b) Flex (bend) the knee (c) and actively straighten the leg again. Be sure to perform the stretch within the limits of your own range and level of comfort. This is an active stretch but it should not be painful. Reps/Sets: perform 1-2 sets of 10 reps per leg.

Gluteus Maximus stretch Muscle used: The gluteals (buttocks) are a muscle group that can also contribute to back pain. Technique: (a) grasp the underside of the thigh about midway between the hip and knee. (b) Raise the opposite side leg and bring it across the body so that it rests above the other leg.(c) Pull your thigh towards the chest until you feel a stretch in the opposite side buttock. Be sure to: increase the stretch, apply pressure in the opposite direction (away from you) with the cross-over leg. It is important that the lower back should remain flat against the floor; do not let the lower back lift off the floor. Sets: perform 3 sets holding for 30 seconds for both legs Kneeling Hip Flexor Stretch

Muscle used: The hip flexors are a group of four muscles. Two of these muscles (psoas) attach to the lumbar vertebrae. Tight hip flexors can contribute to low back pain. Hip flexors often become stiff and tight after lengthy periods of sitting. Technique: (a) Kneel on one leg, the other leg should be placed with the foot on the floor and the leg bent at 90°. (b) Draw in the abs; contract the buttock on the side of the kneeling thigh (c) From the leg that is off the floor; slightly lean forward from the knee and hold for 2-3 seconds (d) The stretch is felt in the hip flexors of the side of the kneeling thigh Be sure to: Maintain an upright posture with the abs drawn in; do not bend forward at the waist. Reps/Sets: Perform 5-10 reps each side, hold each stretch for 2-3 seconds. Perform 1- 3 sets.

Back Flexion Muscle used: As a group, the muscles involved in back flexion help you to bend forward at the waist. Technique: (a) Grasp the legs behind both knees or on top of the legs below the knee (b) Pull legs toward chest and hold (you may lift head or keep the head down. Be sure to lower back should not lift off the floor, do not apply excessive flexion on the spine Reps/Sets: Hold each stretch for at least 20 seconds up to 60 seconds. Perform 2-3 sets. Back Extension

Muscle used: As a group, the muscles involved in back extension allow you to bend your trunk backward. Technique: (a) This exercise is done in prone (facing the floor or mat table). The exercise can be done either on the elbows or with the palms down and the arms extended (like a push-up). (b) From the start position (chest on mat) progress to a press up position with the chest and abdomen off the mat. Be sure the lower body and hips do not lift off the floor. Perform the stretch within the limits of your own range and level of comfort. Reps/Sets: Hold each stretch for at least 20 seconds up to 60 seconds. Perform 2-3 sets.

Basic Draw-in:

Technique: Feet on the wall or the ground, tighten the abdominal muscles to produce a neutral pain-free spine position. Visualize pulling the belly button towards the floor to achieve the neutral spine. This is the position the spine must be kept in during all the exercises. Visualize the abdominal muscles tightening we taped two hockey pucks together and placed them on the abdomen. When the abdominal muscles are braced the abdomen draws in and the pucks lower Reps/Sets: Perform 10 reps in this position; try to hold the position for 5 seconds before you relax, then repeat. Crunch with Draw-In: Technique: Perform a partial crunch without flexing the spine (don’t do a full sit-up). With this exercise the goal is to keep the lower back from lifting off the floor. Try this exercise with the legs off the floor bent 90° at the knees. For this exercise to be most effective, you must draw the abdominal muscles in the entire time, during the upward phase and the downward phase. Also, do not hold your breath during the reps, breathe normally (it’s preferable that you exhale as you lift, inhale as you lower). For added stimulus use a light weight such as a medicine ball or dumbbell. Notice the lower back never lifts off the table. Reps/Sets: Perform 10-20 reps

Dead Bug

Technique: Perform while lying on the back with both legs bent at 90°. Position the legs about 1 foot away from the wall. Maintain neutral spine and remember to breathe. If you cannot use a wall then use a box or do them without a support. The unsupported leg position is still correct; it is more advanced and requires more concentration. Extend one arm forward and the same side leg towards the wall so that the leg is lightly touching the wall.

Reps/Sets: Hold this position for 10 seconds (abs tightened) and then alternate arms/legs for a total of 1 minute. Prone Bridge

Technique: In this position both elbows are bent and in contact with the floor. The arms should be aligned directly under the shoulders. The legs are fully extended with the toes in contact with the floor. Reps/Sets: Perform the bridge position with the abs tightened for 20 seconds.

Be Sure to: Maintain a neutral spine position; the spine is level with the lower extremities.

Two Examples below are incorrect body position during a prone bridge which can create or make back pain worst:

Incorrect form: the hips are too high! Incorrect form: the belly is sagging! Isometric Supine Bridge (Back Bridge)

Technique: This exercise is performed lying on your back with the legs bent at the knees and feet on the ground. Raise the hips off the floor using the gluteals (buttocks) and hamstrings. Tighten the abs and remember to breathe. Reps/Sets: HOLD this position for 30 seconds. Perform 3 sets with 10 bridges in one set. Remember to hold each bridge for 30 seconds.

The gluteus and hamstrings are active to maintain this bridge position. The lumbar spine (lower back) is stabilized and in neutral spine position. A foam roller or volleyball- sized ball can be held between the thighs for added activation of the hamstrings and gluteals. There are many variations of this exercise; this is a basic back bridge that everyone should be able to do.

Side Bridge Technique: Start in a side-lying position. Stack one leg on top of the other leg. Raise the body off the floor. Only the bottom foot is on the floor and the same side arm is on the floor. Sets/Reps: Tighten the abs and hold this position for 20 seconds. Be Sure To: Focus on drawing in the muscles on your side (transverse abdominis), this will support the spine and help maintain the position.

A. Side Bridge B. Side Bridge

Both of these positions are correct. Position A is more advanced because your hips are off the mat. Position B is easier, the upper body is off the floor, and the lower body is supported by the ground. C. Side Bridge

The Standing side bridge is an easier alternative

Modified Prone Cobra

Technique: This exercise works on the lower back muscles. Perform by elevating the trunk slightly off the floor. The trunk only rises a few inches, the abdomen and hips stay in contact with the floor. Contract the gluts with each rep and hold for 2 seconds. 3. Reps/Sets: Perform 2 sets of 10 reps. Quadruped (Birddog)

Technique: Perform by extending one arm forward while extending the opposite leg backward. HOLD for 10 seconds with the abdominal muscles tight. Reps/Sets: Perform 5 reps for each side (total of 10 reps). Alternate opposite side arms and legs

Quadruped Quadruped

Cat/ Camel- this exercise is a motion, not a stretch

Cat Camel

Technique: alternate rounding the back (like a frightened cat) and lowering the spine slightly past neutral (camel). Perform as a cycle of alternating cat and camels. Be Sure To: Do not push at the end range of either motion. Reps/Sets: Perform 2 sets of six cycles. Core Strengthening and Stability on the Physioball

Physioball Wall Squat (with shoulder retraction and protraction)

The wall squat exercise focuses on strength, the core, and posture. Be Sure To: Maintain a neutral spine, keep the head and chin up. Reps/Sets: Perform 10-20 reps, and 1-3 sets. Technique: a. Center the physioball on the back b. Space your feet about hip-width apart or slightly wider, w/ feet in front of body c. Elbows bent 90° and at shoulder level, pull elbows back (retract scapula) Important! Tighten abs (Draw-in) as you prepare to descend (lower) d. Extend your arms forward as you lower your body towards floor. e. Your arms should be fully extended and the top of the thighs parallel to floor at the bottom of the exercise. f. As you ascend (rise) push off from your heels, breathe normally (exhale) g. Begin to retract (pull elbows back) shoulders and flex elbows as you ascend to the start position

Seated Draw-in on Physioball

Technique: Tighten your abs and make yourself as tall and thin as possible. b. Breathe normally; brace the abdominal muscles for a count of 5 then release.

Be Sure To: Maintain a neutral spine, keep the head and chin up. Reps/Sets: Perform 1 set of 10 reps.

Alternating Arm/ Leg March

Technique: Brace the abdominal muscles to stabilize trunk Raise the thigh off floor while raising the arm on the opposite side. Hold this position for 3 seconds. Alternate by repeating opposite side

Be Sure To: Remember to breathe! Reps/Sets: Perform 1 set of 10 reps. Crunch on the Ball

Technique: Brace the abs and perform a partial crunch, contract the abs for the entire set. Reps/Sets: Perform 10 reps forward. Perform 10 reps to the right. Perform 10 reps to the left

Bridges on the Physioball

Prone Bridge Back Bridge

Technique: Prone Bridge: with the elbows on the ball and up on the toes, brace the abs (stabilize the spine) Back Bridge: raise your hips so that your back is in line with your thighs. Contract the hamstrings and the gluts. The exercise can be made more effective by squeezing a volleyball-sized ball between the thighs. Reps/Sets: Hold each position for 20 to 60 seconds. Perform 1-3 sets each. Prone Flies

Technique:: With the arms out in front, and thumbs up, raise the arms up to shoulder height. Finish: Hold for 3 seconds Reps/Sets: Perform 1 set of 10 reps (hold each rep for 3 seconds)

Start Finish

Prone Diagonals

Technique: a. Raise one arm and the opposite side leg Be Sure To: Hold for 3 seconds Alternate by repeating the opposite side Initiate the upper body lift from the shoulder blades Reps/Sets: Perform 1 set of 10 reps each side Hold each rep for 3 seconds Questionnaire Survey Results from Franklin Pierce Students: Regarding Back Pain

Our group collected 77 completed surveys. We decided to limit our focus to respondents falling into the target age group of 18-24, which includes responses from 61 people. Research shows that 50% of young adults between the ages of 18-24 will experience their first bout of back pain.4 We wanted to compare our findings to that of other current studies.

The results from our survey show that 77% of young adults have experienced back pain within the last twelve months. From the 47 respondents who had back pain: 32 experienced back pain from long periods of sitting, 21 from sleeping, 17 when bending over, 15 from sports, 13 from lifting objects, twisting back, and backpack/carrying bag, 9 from getting out of bed, and 7 from walking.

Sixty-eight percent of people who reported back pain during the last twelve months indicated that their pain interfered with their normal daily routines and/or social activities. Thirty-two percent of those people have visited a medical professional about their back pain.

One cause of back pain is associated with a sedentary lifestyle. For this reason, our group wanted to see if there was a correlation with young adults who have back pain and how much they exercise. Our survey shows of young adults who have back pain, 9% do not exercise, 38% exercise 1-2 days a week, 34% exercise 3-5 days a week, and 19% exercise every day.

One purpose of our project was to create a back pain prevention program consisting of exercises intended to strengthen, stretch, and stabilize the back. We wanted feedback to determine if our target population would perform a back pain prevention plan on their own if given the information. Of the respondents who have had back pain, 58% said they would be willing to follow an exercise plan focusing on their back.

Since our survey targeted college students, we wanted to quantify their posture while studying. Of those students with back pain, 42% slouched, 27% lean forward, 21% sit erect, and 10% sit in ‘other’ positions that they indicated as lying in prone, lying down, or a combination. Ten Safety Tips When Lifting Heavy Objects

1) Stand close to the load and center yourself over it with your feet shoulder width apart

2) Tighten your abdominal muscles

3) Keeping your back straight, bend your knees and squat down to the floor Image 5

4) Get a good grasp on the load with both hands

5) Keeping the load close to your body use your leg muscles to stand up lifting the load off the floor

6) Your back should remain straight throughout lifting, using only the muscles in the legs to lift the load

7) Do not twist your body when moving the load. Instead take small steps with your feet turning until you are in the correct position

8) Again bend at the knees using only your leg muscles and place the load in the appropriate spot

9) When moving extremely heavy objects, push rather than pull the item.

10) Wear shoes that are flat or have very low heels. The US Department of Labor, Occupational Safety and Health Administration have published a useful checklist for safe computer workstation positioning.

Complete this easy evaluation below by answering yes or no to each point. A "no" response indicates that a problem may exist.

Working Postures 1. Head and neck to be upright, or in-line with the torso (not bent down/back). 2. Head, neck, and trunk to face forward (not twisted). 3. Trunk to be perpendicular to floor (may lean back into backrest but not forward). 4. Shoulders and upper arms to be in-line with the torso, generally about perpendicular to the floor and relaxed (not elevated or stretched forward). 5. Upper arms and elbows to be close to the body (not extended outward). Image 6 6. Forearms, wrists, and hands to be straight and in-line (forearm at about 90 degrees to the upper arm). 7. Wrists and hands to be straight (not bent up/down or sideways toward the little finger). 8. Thighs to be parallel to the floor and the lower legs to be perpendicular to floor (thighs may be slightly elevated above knees). 9. Feet rest flat on the floor or are supported by a stable footrest.

Seating 10. Backrest provides support for your lower back (lumbar area). 11. Seat width and depth accommodate the specific user (seat pan not too big/small). 12. Seat front does not press against the back of your knees and lower legs (seat pan not too long). 13. Seat has cushioning and is rounded with a "waterfall" front (no sharp edge). 14. Armrests, if used, support both forearms while you perform computer tasks and they do not interfere with movement.

Keyboard/Input Device 15. Keyboard/input device platform(s) is stable and large enough to hold a keyboard and an input device. 16. Input device (mouse or trackball) is located right next to your keyboard so it can be operated without reaching. 17. Input device is easy to activate and the shape/size fits your hand (not too big/small). 18. Wrists and hands do not rest on sharp or hard edges. Monitor 19. Top of the screen is at or below eye level so you can read it without bending your head or neck down/back. 20. User with bifocals/trifocals can read the screen without bending the head or neck backward. 21. Monitor distance allows you to read the screen without leaning your head, neck or trunk forward/backward. 22. Monitor position is directly in front of you so you don't have to twist your head or neck. 23. Glare (for example, from windows, lights) is not reflected on your screen which can cause you to assume an awkward posture to clearly see information on your screen.

Work Area 24. Thighs have sufficient clearance space between the top of the thighs and your computer table/keyboard platform (thighs are not trapped). 25. Legs and feet have sufficient clearance space under the work surface so you are able to get close enough to the keyboard/input device.

Accessories 26. Document holder, if provided, is stable and large enough to hold documents. 27. Document holder, if provided, is placed at about the same height and distance as the monitor screen so there is little head movement, or need to re-focus, when you look from the document to the screen. 28. Wrist/palm rest, if provided, is padded and free of sharp or square edges that push on your wrists. 29. Wrist/palm rest, if provided, allows you to keep your forearms, wrists, and hands straight and in-line when using the keyboard/input device. 30. Telephone can be used with your head upright (not bent) and your shoulders relaxed (not elevated) if you do computer tasks at the same time.

General 31. Workstation and equipment have sufficient adjustability so you are in a safe working posture and can make occasional changes in posture while performing computer tasks. 32. Computer workstation, components and accessories are maintained in serviceable condition and function properly. 33. Computer tasks are organized in a way that allows you to vary tasks with other work activities, or to take micro-breaks or recovery pauses while at the computer workstation. References

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Image References:

12. Image 1: Vertebral Column. Infovisual website. Available at: http://www.infovisual.info/03/021_en.html. Accessed October 12, 2009

13. Image 2: Spindylolisthesis. Backpain – guide website. Available at: http://www.backpain- guide.com/Chapter_Fig_folders/Ch06_Path_Folder/Ch06_Buttons/06- 5%20AF%20Spondylolisthesis.jpg. Accessed October 12, 2009

14. Image 3: Disc Herniation. Regenerative Sciences website. Available at: http://www.regenexx.com/wp- content/uploads/2008/10/disc-herniation.jpg. Accessed October 19, 2009.

15. Image 4: Lumbar Stenosis. Available at: http://ubiquity- design.com/wordpresscontent/uploads/2009/02/lumbar_stenosis_intro01.jpg. Accessed October 18, 2009.

16: Image 5: Beernink K, Carhart C, Woolfenden C. Workstation Ergonomics. Available at: http://health.wpri.com/TextItem.aspx? id=1122. Accessed on: October 25, 2009.

17: Image 6: Body Mechanics. Available at: http://givingcare.org/body_mechanics.htm. Accessed on: October 25, 2009.