Lower back pain is a very complex problem and may have many causes. One cause is when spinal tissue failure occurs as a result of high compression forces applied through the spine leading to spinal injuries. High spinal compression forces may lead to micro fractures in the vertebral endplates, compression fractures of the vertebral bodies and damage to the spinal discs (1-3).
Activities which cause high spinal compression forces include:
Certain body postures also create higher compression forces through the spine than others. For example, bending the spine while lifting, increases the pressures on the spinal discs by more than 100%. Spinal bending combined with twisting increases spinal disc pressures by more than 400%. On the other hand, when people recline backwards in a chair, even while adopting a slouching posture, spinal disc pressures reduce by 50-80% – a posture most of us adopt when we’re getting tired during extended bouts of sitting. Sitting up straight in a chair actually creates twice the spinal compression compared with reclining backwards in a chair – something to tell your granny or your teacher when they criticize your reclined slouching posture!
In 1979, it was noted that when heavy lifting was performed while holding one’s breath (for a few seconds), the intra-abdominal pressure was raised, the spinal extensor muscles activity reduced and both led to reduced compression loading on the lumbar spine, reducing the risk for spinal injury. However, if the heavy lifts extended for longer than a few moments, the breathe was released and the intra-abdominal pressure fell to much lower levels, reducing this spinal support mechanism substantially (5). This reduction in spinal compression due to raised intra-abdominal pressure was supported by research published in 2003, 2006 and 2010 and showed that the greatest benefit occurred when the body was in flexed (bent) postures (6-8).
The question arises as to how raised intra-abdominal pressure reduces spinal compression and helps to protect the spine from spinal compression failure leading to spinal injury and lower back pain.
Both abdominal and spinal extensor muscle contraction cause an increase in the spinal compression forces. However, the abdominal muscle contractions (0- 40% MVC) also assist in raising the intra-abdominal pressure, and when doing so, the net forces on the spine result in reduced spinal compression. In these circumstances it was also found that there was a reduction in the activity of the erector spinae muscles, with a greater reduction in these muscles’ activity corresponding to a greater increase in intra-abdominal pressure (8).
Furthermore, a 2013 published study revealed that chronic lower back pain sufferers who were experiencing a remission from their pain still exhibited lower levels of agonistic abdominal muscle activity and higher levels of antagonistic paraspinal muscle activity when compared to healthy individuals when performing spinal flexion (stooping/bending) with or without handling a load. This alteration in their abdominal and spinal muscle recruitment activity/ patterns could result in increased spinal loads (not measured in their study) and possibly contribute to the recurrence of lower back pain in individuals where these altered recruitment patterns have become the norm (9). On the other hand, research published in 2011 showed that activation of the core muscles showed no improvement in spinal stability, casting doubt on the mechanism in which core muscle rehabilitation is used to assist in the treatment of chronic lower back pain (10).
Adams M.A.; McNally S.D.; Chinn H.; Dolan P. (1994). Posture and the compressive strength of the lumbar spine. J Biomech. 27(6):791-791.
Nachemson A.L. (1981). Disc pressure measurements. Spine. 6(1):93-7.
It’s strange thing to think that your elbow angle is possibly related to your neck pain. But, it’s true. Well, more specifically, it’s true in certain situations. Read on:
Neck pain is sometimes caused as a result of tension or spasm in the upper trapezius muscle. The upper trapezius muscles are the upper fibers of the large diamond shaped trapezius muscle that covers the back of your neck and middle back, illustrated below. As you can see, the upper fibers connect the neck and the shoulder, and it’s normally in the mid belly region of these upper fibers that people experience neck pain.
Why does your upper trapezius muscle become inflamed or go into spasm and create your neck pain?
Well, one common reason is because of stress (which can cause inflammation of the trapezius muscle in the absence of trigger points and muscle spasm).
Another reason is because of fatigue of the upper trapezius muscle. When your upper trapezius muscle fibers are made to work under low loads for extended periods of time, they become fatigued and you are then likely to experience pain in the presence of spasm.
What causes the upper trapezius muscle to fatigue while you sit behind your computer and work?
There are a number of factors surrounding your computer workstation that can cause your upper trapezius muscle to fatigue and create neck pain for you.
One of the least well known reasons to creating fatigue of your upper trapezius muscle and hence your neck pain, is the angle of your elbow while you work.
A very interesting study found that when you work on your keyboard and mouse, the angle that you keep your elbow at will determine the level of your upper trapezius muscle activity and your neck pain. Keeping the angle of your elbow greater than 90 degrees, helps to reduce the fatigue of the upper trapezius muscle fibers and reduces neck pain.
This elbow angle position is important when it comes to where you position your keyboard and mouse as you work at your desk. As I’ve mentioned before in other posts, your screen needs to be arms length away from you when you’re leaning backwards against your chair’s backrest. In contrast to a closer position of the computer monitor than most people tend to adopt, the keyboard and mouse need to be positioned further away and not too close to yourself.
As you sit and type and mouse, your elbow angle must be open (i.e. greater than 90 degrees and up to about 120 degrees). Working on a desktop computer, this elbow position may be more intuitive, however, be more aware of your elbow angle when you work on your laptop as well. People often work on laptops in constrained positions and places, with the laptop quite close to you. Learning how to setup your computer workstation correctly is important to help reduce or prevent the common aches and pains us modern workers experience.
Where do you position your keyboard and mouse when you work? And do you suffer from neck pain?
Gawke J.C., Gorgievski M.J., van der Linden D. 2012. “Ofﬁce Work and Complaints of the Arms, Neck and Shoulders: The Role of Job Characteristics, Muscular Tension and Need for Recovery.” Journal of Occupational Health 54: 323–330.
Bansevicius D., Westgaard R.H., Stiles T. 2001. “EMG activity and pain development in fibromyalgia patients exposed to mental stress of long duration.” Scandinavian Journal of Rheumatology 30 (2): 92-98.
Marcus M., Gerr F., Monteilh C., Ortiz D.J., Gentry E. et al. 2002. “A prospective study of computer users: II. Postural risk factors for musculoskeletal symptoms and disorders.” American Journal of Industrial Medicine 41: 236-249.
If you’ve recently experienced a soft tissue injury, go see your doctor or physiotherapist as soon as possible to determine how serious your injury is and to find out how to allow swift and proper healing to occur.
In addition, the first 24-48 hours are very important following a soft tissue injury. What you do or do not do in this time may or may not prevent unnecessary secondary tissue damage following the original injury.
When tissue damage has occurred, the cells of the affected tissue break open releasing their contents into the surrounding area. This causes a whole set of inflammatory chain reactions that result in an increase in the blood supply to the area, further inflammation and swelling. A certain amount of inflammation is necessary for your healing to occur, however, too much inflammation, bleeding and swelling cause more damage than the original injury alone.
If the principles of RICE are not applied quickly following a soft tissue injury, too much bleeding, inflammation and swelling will occur. The side effects of this is that the swelling will cause compression of the surrounding tissue and reduce its oxygen supply. This in turn can lead tissue damage of this surrounding tissue increasing the general weakness of the area.
Generally speaking, the principles of RICE should be applied to prevent this unnecessary extension of your soft tissue damage:
R – Rest
One of the most important things to do when you have an injury, is to rest the affected area immediately and to reduce your general activity as well. This helps to reduce the general circulation of your body and in the injured area thus reducing the bleeding and swelling around your injury, helping to prevent secondary tissue damage.
Then, following your initial injury, you need to continue to rest the injured area through possibly restricted weight bearing and/or movement as determined by your doctor or physiotherapist according to the degree of your injury.
This is important since your body can’t heal if you keep straining your injured tissue. Think of a bridge that has collapsed and is being repaired. How helpful is it if people want to keep driving cars across it until it’s structurally sound again? Tissue damage in the body is a lot like that metaphor. If you place undue strain on a body part that hasn’t fully healed yet, you will cause mechanical failure of the injured tissue, placing you back at square one and possibly creating more damage.
The general guide to healing of injured tissue is 6 weeks to 50% healing and 3 months to 70-80% healing. This is true for both bone and soft tissue. Remember that ligaments and tendons also play a structural role in your body, so if you have injured 30%, 50%, 70% of your ligament or tendon, this will determine how much the rest of the remaining tissue will be available to take over the function of your damaged tissue. This will also determine how much you need to rest it, if you need crutches, strapping, a brace etc.
Ice should be applied immediately following a soft tissue injury. The application of ice helps to cause constriction of the blood vessels and limit further damage. The ice will also lower the metabolic rate of the tissue that you apply it to, thus reducing the demands of oxygen and nutrients in the area. This is useful since the circulation which is crucial in the function of tissue metabolism would have been damaged to some degree.
Another benefit of applying ice is that as it reduces the inflammation and swelling in the area, it will also reduce your pain and therefore any muscle spasm that would’ve occurred as the body tries to protect itself from unwanted movement.
Be careful not to apply ice directly to the skin or to use it for too long, you don’t want to create ice burn. The general recommendation is to apply the ice for 15-20 minutes every 1-2 hours. Apply it less often over the 48 hr period following your injury as your swelling and inflammation reduces. People who have poor circulation or a poor nerve supply to the area such as diabetics, smokers, people with paralysis, Raynaud’s disease, peripheral vascular disease etc. need to be careful when they use ice to avoid ice burn and tissue damage.
C – Compression
Compression of the injured area helps to reduce bleeding and swelling and the resulting secondary tissue damage if too much bleeding and swelling occurs. It also helps in part to provide structural support to the injured tissue .
The trick with compression is not to apply it too tightly which can severely reduce blood supply to the area altogether and also result in tissue damage.
The skin should not be white, tingly or blue (all indications that the compression bandage is too tight). The compression bandage should be placed in layers that partially overlap each other (about 50% overlap layer upon layer) and not in layers positioned directly over each other. If the bandage is applied in the latter scenario, it is likely that the bandage will cause too much direct compression and substantially reduce the bloody supply to the area.
There are special strapping techniques to create support for certain ligaments and tendons that are damaged until they are healed that your physiotherapist can teach you. If you’re not comfortable strapping, it might be better to buy an ankle support which won’t require you to know the intricate strapping methods and is more likely to be safe. Just make sure that you buy the correct size for your joint.
E – Elevation
Again , elevation is there to help with the circulation. Elevating the injured area helps to reduce the blood flow to the area, and thus the swelling. It also helps to encourage the return of venous blood and lymph into the general circulation which helps with tissue healing.
Khan K., Bruckner P., (2011). Clinical Sports Medicine 4th Edition. Australia. McGraw-Hill Australia
If you’re one of the millions of office workers in the world, you will appreciate being able to sit comfortably for long hours at your desk.
The chair is the centre of your computer and desk workstation. Everything pivots around it. Do you know to position your chair correctly so that you’re comfortable while you work? Follow these 4 steps:
1. Elevate Your Chair to the correct Height
The first thing that you need to do is to set the height of your chair correctly. How do you know if your chair height is correct? It is not whether your feet touch the ground or not. If you use this as your guide, you are likely to set your chair too low, which will result in you shrugging your shoulders to reach your desk and your keyboard. Shrugging your shoulders for long periods at your desk puts you at a high risk of neck pain. Neck pain is very common among office workers and a low chair position in relation to one’s desk is one of the reasons why that this is so common.
So, to find the correct height for your chair, lean backwards against your backrest and elevate your chair until you are able to work at your desk and your keyboard with your shoulders relaxed. If your feet dangle, don’t lower your chair back again, rather get a footrest. If there is no money for a footrest, use some books or even reams of paper to support your feet. Don’t rest your feet on your chair legs, this will strain your back. Also, don’t ignore it if your feet don’t firmly touch the ground. It makes a greater difference than you think to use a support for your feet, even if it’s only a slight elevation that is necessary for you to be comfortable at your desk.
2. Bring Your Chair Closer to Your Desk
You might also need to bring your chair close enough to your desk. You need to bring your chair a lot closer to your keyboard and desk than you think you do. If you don’t, you will find yourself leaning forwards away from your backrest, which can lead to lower back pain.
If the armrests are a problem and preventing you from bringing your chair close enough to your desk because they are fixed, get someone from maintenance to remove them. If you have adjustable armrests, first try to lower them, but if the correct height of your chair causes them to knock against your desk, then raise them slightly to slide just over your desk.
“Armrests that can’t adjust low enough should be adjusted to slide just over your desk” by CS Body Health cc. All Rights Reserved. 2016
3. Incline Your Backrest Backwards to -8 Degrees:
Some people believe that if their chair is upright, they are sitting in good posture and sitting correctly. Good posture for the spine is maintaining the s-curve of the spine. Sitting too upright places higher loads on the spine than if it is reclined backwards. If you sit too upright, you will fatigue faster.
4. If Your Chair has an Adjustable Backrest
If your chair has an adjustable backrest, you need to make sure that the curve of the backrest is placed in the small of your back. This is to ensure that the s-curve of your spine is supported while you sit for long periods at your desk to help reduce lower back pain.
Neck pain is a common problem for at least 30-50% of the population at some point in their lives. Neck pain, however, isn’t the only problem that some people may encounter. Some people suffering from neck pain may also experience the bizarre phenomenon of feeling off balance or even falling over in association with their neck pain. Why is this?
If you are experiencing these added symptoms (and more – e.g. dizziness, problems with vision etc.), you would quite understandably be concerned that something more sinister might be at play. To rule this out, I highly recommend that you go see your doctor for further tests. This is especially important if you’ve recently been in any falls, car accidents, suffer from rheumatoid arthritis or any other systemic illness or cancer (to name just a few things that may contribute to structural weakness in the neck area – there are more things that can, but discussing this is not the point of this article).
Once you have been cleared of anything sinister, the question to ask is, why are you stumbling around, losing your balance or even falling over like a drunk person?
” Schematic of mammalian muscle spindle” by Neuromechanics under Licence in the Public Domain
There is a structure called a muscle spindle that is a key element in this phenomenon, which is found in an incredibly high density in the upper region of the neck (200 muscle spindles per gram of muscle in this area). It is also found in other parts of the body, but not in quite the high proportion that it occurs in the upper region of the neck (for example, there are only 16 muscle spindles per gram of muscle in the pincer muscle of the thumb).
The importance and function of the muscle spindle is that it detects changes in the length of the muscle fiber. This in turn helps the body part associated with those specific muscle spindles, to determine where it’s positioned in space. It also helps to set the resting tone (the resting degree of muscle contraction) of the muscle concerned as well as playing a protective function for the muscle. The protective function occurs through the feedback the muscle spindle provides when the muscle is overstretched, resulting in immediate contraction of the muscle to prevent overstretching and injury.
In the upper region of the neck, these muscle spindles play an enormous role in the postural control of your whole body and your overall ability to balance through their function in association with other systems found in the inner ear, eyes and central nervous system.
Something that we as therapists know, is that the whole body follows the head. In other words, if your head turns right, your body will follow and also lean towards that direction. Think about when you’re driving the car and you turn to look at something in the road, if you’re not careful, before you know it, your car too has veered off in that direction. This is all due to these muscle spindles in the upper region of the neck and their complex interaction with your other balance and positioning sensing systems in your inner ear, your eyes and your central nervous system.
I will always remember a knee patient I was rehabilitating years ago following his ACL surgery. He was absolutely useless at any balance exercise and made very poor progress despite practice. When I finally made him stand up straight to check his standing posture, I discovered that his resting position for his neck was tilted slightly to one side. To him, this felt absolutely normal and upright! Once I had corrected this so that he could sustain a proper upright standing posture, he found any balance exercises a whole lot easier and his rehabilitation, especially the balance and control elements, improved rapidly from there on out. This again illustrates the importance of these muscle spindles in the upper neck muscles!
So, one of the reasons your neck pain may be causing you to stumble, lose your balance or even fall over, is that you may have some malfunction of these upper neck muscle spindle fibers and their interaction with the associated balance and positioning sensing systems of your inner ear, eyes and central nervous system.
This can be due to a few things:
What can you do about it? Your OMT specialised Physiotherapist has a number of techniques to assist you. If you click on the link, you can find someone close to you to help.
Guzman J., H. E.-J. (2008). A new conceptual model of neck pain linking onset, course and care: The bone and joint decade 2000-2010 task force on neck pain and its associated disorders. Spine, 33(4S), S14-S23.
Guzman J., H. S.-J. (2009, February). Clinical practice implications of the bone and joint decade 2000-2010 task force on neck pain and its associated disorders. Journal of Manipulative and Physiological Therapeutics, 32(2S), S227-S243.
J. Treleaven. (2008). Masterclass: Sensorimotor disturbances in neck disorders affecting postural stability, head and eye movement control. Manual Therapy, 13, 2–11.
D. Falla. (2004). Masterclass: Unravelling the complexity of muscle impairment in chronic neck pain. Manual Therapy, 9, 125–133.
If you’ve been following my posts, you’re starting to realise that I keep harping on about how common neck pain is among office workers. During my pre-corporate practice days, lower back pain and knee injuries were the most common ailments I treated. Once I moved into the corporate environment though, I was totally amazed at the high incidence of neck pain I encountered.
There are various reasons for this high incidence of neck pain in an office environment. One large part is people’s posture while they work at their desks day in and day out (read my post on 4 monitor positions to cause neck pain). Another reasons for this higher incidence of neck pain is the high stress levels people are exposed to in the modern day office environment (read my post on stress and neck pain).
More and more computers are taking over and we’re working with less and less paper in our offices. A completely paperless office though, has not yet arrived for most of us. Does it really matter?
Who of you find yourself constantly referring to papers, writing on documents, capturing data from sheets and then working with the information on your computer as part of your job? I find this quite common among book keepers, data capturers, etc.
How does working between papers and a computer increase your risk of developing neck pain? There are a number of factors to consider in these scenarios.
Lower back pain is a very common ailment affecting a large portion of the population at any given time. It’s also generally accepted that we are suffering from an obesity epidemic in South Africa and in many other countries across the world.
I have had many patients who have come for treatment report that their doctor has blamed their lower back pain on their weight. Being overweight is often a touchy subject for people carrying the extra pounds, so I’ve never been very comfortable making those types of associations or discussing weight issues with these patients. Moreover, I’ve also had so many skinny patients with severe cases of lower back pain that I preferred to focus on the structural causes of the presenting lower back pain in these individuals rather than any weight issues.
However, is this the correct approach? Does one’s weight impact on one’s experience of lower back pain and should it really be swept aside like I tend to do out of deference to people’s feelings? I thought it might be useful to look at the research to see what studies have found, but first of all, we need to define the parameters of our discussion.
What does it mean to be overweight, and what does it mean to be obese? According to the Obesity Organisation, a body mass index (BMI) of 24.5-29.9 will place you in the overweight category, a BMI of 30-39 will mean that you are obese, and a BMI of 40+ will mean that you are morbidly obese.
How do you go about calculating your BMI?
To calculate your BMI, divide your body weight (in kilograms) by your height squared (in centimeters).
Bear in mind, however, that if you’re very muscular, pregnant or breast feeding, your BMI will not be a proper indication of your health.
Use this BMI Calculator to easily workout your BMI.
Right, now that you know your BMI and in which bracket you fall, let us return to my original question: Does being overweight or obese have an influence on your lower back pain?
Some researchers did a literature review of all studies performed in relation to body weight and lower back pain up to 2009 (click here to access the article) and found that there was an association between carrying extra weight and a higher incidence of lower back pain. They also found that obese people (BMI of 30+) had more lower back pain than overweight people (BMI of 25-29). This shows an increasing correlation between your weight and your experience of lower back pain. In other words, the more weight that you carry, the greater your risk of experiencing lower back pain.
A more recent study published in 2015 (click here to access this article) also probed the associations between body weight and the experience of lower back pain. Unfortunately this study only focused on men, however, they did look at the associations of weight gain and lower back pain over time (decades). They found that an increasing BMI of overweight and obesity was linked an increased risk of experiencing radiating lower back pain (in other words lower back pain that has pain going into one or more legs). What was interesting though, was that they found that generalised lower back pain (known in the medical community as non-specific lower back pain) was not linked to weight gain at all.
This implies that not all lower back pain is affected by your weight, which from experience as a clinician, I know to be true.
So, after all of that, what is the ‘take home’? Basically, if you are carrying extra weight and are either overweight or obese, you are more likely to experience lower back pain. However, (and logically), not all lower back pain is influenced by weight gain.
What types of lower back pain are influenced by being overweight? I will explore this in a future post.
Children. They’re little bundles of joy and we love to pick them up and cuddle or play with them, but who of you parents find that since you have kids, you’ve been experiencing an ache in your lower back?
Why is this? They’re small, we’re big and surely we’re strong enough to move them around anyway we like? Why then do some of us get this nagging pain in our lower backs?
Well, part of the problem lies in the fact that they’re small and we’re big, or, rather tall. When we go to pick these little people up, it means that we have to bend down quite low, close to the ground to reach them. What this means is that we inevitably need to do one of two things:
Ah, the old adage I hear you comment. We know this already! Really? If so, why are you still getting lower back pain? Do you really understand what you need to do? (Sign up for my back class for parents)
Most of us don’t like bending our knees when we go down quickly to pick something up off from the ground. Why is this? Well, it takes more energy to bend your knees than to bend your back, and all of nature generally likes to take the easy route.
We know, however, that bending our backs to pick up things (such as our children), is not good for us and leads us to develop lower back pain. Part of the reason that bending your back is bad for you, is because when you bend your back, you lose the curve in your lower back. You’ll notice that this is a recurring theme in all my posts if you’ve been following them.
The reason why I keep harping on about your spinal curve is that it is very important. Your spinal curve helps reduce the loading on your spine and thus the compressive and shearing forces on your spinal discs and joints. When all these forces become too high, you get mechanical failure that leads to lower back pain. 80% of the world’s population will suffer from lower back pain at some point, so this tells you how important it is to sit up and take note, and the note you need to make is: keep your spinal curve intact when you move and sit, and lift things, and especially when you pick up your children from the floor.
Ok, ok, so we finally agree that it’s not worth your while to take the easy way and quickly bend your back to to lift your children up from the floor. Nobody enjoys lower back pain. But, if you are observant, you’ll find that bending your knees alone won’t help you maintain your spinal curve either.
Let’s try a little experiment: Place your hand in the small of your back and keeping your legs together, bend your knees.
So, if you actually took the time to try this, you’ll find that bending your knees with your legs together really is not very helpful and creates a lot of work while still putting your back at risk of developing lower back pain.
The solution? Open your legs. Wide. Much wider than you generally think you need to or even want to. And then jagger your legs so that one leg is more forwards than the other. Then, bend your knees. Can you feel how much easier it is on your legs and your lower back? And did you notice how much easier it was to reach the floor, while maintaining your lumbar curve? And did you also notice how much stronger you are in this position compared to all the others we’ve discussed above?
The interesting thing is, if you have lower back pain, you know that your back will only let you lift your child as in the photo above and not with you bending your back. Maybe we should all take a bit more time to think about our bodies and move to keep ourselves safe, healthy and pain free.
Do you feel you and your friends/family/carers need more help in correcting your postures when moving your children? Why not create a group booking for my back pain prevention class for parents and carers?
Anterior knee pain is a common injury for cyclists (read my post on cycling and knee pain). This injury is also present in the general population, typically amongst growing children and teenagers. Overall it affects 25% of the population at some point in their life.
Anterior knee pain occurs when the quadriceps muscles are unable to support the mechanical requirements placed upon them through activities in daily life (such as climbing up or down stairs) or sport and recreational activities (such as cycling or mountain climbing).
Mechanical failure of the quadriceps muscles results in compression of the underside of the knee cap (the cartilage) onto the thigh bone (femur) below. This results in pain and inflammation in this area and makes loading of the knee and knee cap as well as bending of the knee, painful. The result is a reduced ability to participate in previous activities, especially sport.
In cyclists, anterior knee pain is commonly created as a result of too rapid or too many increases to a training schedule, but, importantly, research also shows that anterior knee pain can also be due to your bike’s saddle height being set incorrectly.
From the research, it appears that the height of your bike’s saddle has an influence on the amount of compression that is placed through the knee cap, thus influencing the development of anterior knee pain or not. The lower the height of your saddle, the higher the compressive forces on your knee cap and the greater your risk of developing anterior knee pain.
Apparently there are a number of recommended ways to set your saddle height correctly, but not all are supported by scientific research. According to a research review published in 2011, the researchers determined that using the knee flexion angle method was the preferential method to determine the correct saddle height for your bike and that when using this method, your knee angle should be set at 25-30 degrees. Another benefit of this saddle height position is that it optimizes your oxygen consumption when cycling at a steady pace.
Now, how do you go about setting your bicycle saddle height according to the knee flexion angle method with the knee angles set between 25-30 degrees?