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.
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?
People who suffer from lower back pain often find it aggravated by driving, or some people who drive a lot find themselves experiencing lower back pain.
Either way, there are a few things to be aware of regarding your posture in the car that will help both scenarios reduce their lower back pain and improve their driving experience.
Your lumbar curve is there to help reduce the loading on your spine. When you slouch, you increase the pressure on your spinal discs and increase your risk of developing a spinal disc problem that may result in lower back pain. The backrest of your chair is specially shaped to help maintain your curve. To gain the benefit of your backrest, ensure that your buttocks are positioned right back against the backrest and that you are leaning backwards into it.
2. In order to sit properly while you drive and maintain your lumbar curve, you need to position your legs at the correct distance from the pedals to prevent tight hamstrings on stretch from flattening your lumbar curve (read my post on tight hamstrings and lower back pain).
Your hamstrings attach to the bottom of your pelvis and go on stretch when you straighten your knee. If you have tight hamstrings, when you straighten your knees to reach/press down on your car pedals, the stretch in your hamstrings will result in your pelvis being rotated backwards and your lumbar curve flattening, increasing the pressure on your spinal discs and increasing your risk of developing lower back pain.
In order to determine the correct distance of your car seat to the pedals, place one hand in your lower back and feel the curve of your lower spine, then move your seat forwards and back until you can comfortably reach the pedals while still maintaining your lower/lumbar spinal curve.
3. Incline your car seat’s backrest to -8 degrees to reduce the loading on your lumbar spine and reduce spinal fatigue.
There is more loading on your spine when your backrest is upright than when it is reclined backwards. You instinctively know this, and when you are tired from sitting upright for too long, you will intuitively move your buttocks forwards on the chair seat and lean backwards to take the strain off your spine. Thus, positioning your car seat too upright will cause fatigue of your back and increase your risk of developing lower back pain if you are driving for long periods of time.
4. Elevate/lower your chair so that your hips are 90 degrees or less. If your hip angle is too sharp, this will also increase your risk of slouching in your chair, which in turn will lead to increase pressure on your spinal discs and increase your risk of developing lower back pain. If your seat does not allow you to sit high enough, help yourself by sitting on a small cushion.
5. Move the steering wheel up/down/forwards and back until you find a comfortable distance from yourself to the steering wheel. Your elbows should be slightly bent. This will prevent your shoulders from fatiguing, which when it occurs, will also increase your spinal loading and spinal fatigue when driving and increase your risk of developing lower back pain or aggravating your current pain.
6. Stretch your hamstrings (read my post on how to stretch your hamstrings if you have lower back pain) if they are tight to help yourself maintain good spinal posture when you drive.
Neck and lower back pain are such common complaints that we all know someone (if it’s not ourselves) who has experienced at least one of these complaints. There are many causes for neck or lower back pain. These can include different types of injuries, disease processes, genetic predispositions, and most importantly and commonly of all, our posture. Our posture at work and our posture at home and at play.
Our work posture is getting more and more attention, especially since the advances in technology have relegated most of us to work behind a computer for long hours each day. There are a host of things to consider in our work environment that can negatively affect our posture and cause our neck or lower back pain.
Part of my job is going around performing office ergonomics for people. One of the most common things I hear is people blaming their chair for their neck or lower back pain. Most often, however, this is not correct and the real culprit is the monitor and where it has been positioned on the desk. Luckily, this is a much cheaper and easier solution to the problem.
Your poor monitor position (read my post on 4 poor monitor positions that cause neck pain) is definitely one of the first places to look if you suffer from neck or lower back pain and you think your work posture is to blame. There are a number of factors to consider in relation to your monitor position, but one very important and neglected element is the correct monitor distance that your monitor is positioned away from you while you work.
If your monitor is positioned too far away from you, you will find yourself leaning forwards in order to see your screen better, creating all sorts of problems in your spine (especially in your neck and lower back) and over activating your shoulder muscles, all leading you down the path of aches and pains.
So what is the correct distance that you should place your monitor?
Generally, your monitor should be positioned a lot closer to yourself than you think it should. And if you don’t believe me, ask yourself why you keep leaning forwards when you work.
How do you determine the correct distance that you should position your monitor at? I call it the “Frankenstein” test.
Closer than you think? Give it a try and remember to keep leaning back against your chair’s backrest. Your backrest is there to help keep you in good posture while you work. A combination of those two factors (leaning back in your chair and having your monitor at the correct distance away from you) will go a long way to reduce your neck or lower back pain associated with poor working posture.
One of the worst things about lower back pain is that it stops you doing a lot of your normal activities, sports or exercises. From experience, I’ve watched lower back pain reduce some very active people into couch potatoes due to their lower back pain preventing them from following their normal sporting routines. These individuals often struggle to find other ways to keep fit until their lower back pain settles.
A definite exercise no-no for lower back pain is sit ups (read my post on sit ups and lower back pain), or some form of them. Since core exercises are an integral part of any training program, many people must ask how they can exercise their abdominal muscles while they’re suffering from lower back pain and until their lower back pain settles?
Enter: The Plank.
The plank is one of my favourite exercises. It’s easy to perform at home and it will give you a good overall work out. The plank is a lot harder than it looks.
In addition to working your abs, the plank is also a very good exercise for protecting your shoulders against rotator cuff injuries. It accomplishes this by working your shoulder stabilisers while simultaneously working your abs. The plank has another added benefit of strengthening your spinal extensor muscles at the same time as well. It’s an excellent overall core strengthening exercise and should routinely be a part of any training programme.
When Performing the plank, there are a few things to keep in mind:
McGill S. (2010). Core Training: Evidence Translating to Better Performance and Injury Prevention. Strength and Conditioning Journal, 32 (3), 33-46.
A ‘6-pack’ – the ultimate fit and healthy look! One of the most common ways to go about getting your awesome abs is to perform loads of sit ups. This must be one of the most common exercises performed in the gym, and judging by the photo below, in the armed forces as well (read my post on why your abs are important Part 1).
Most people are very careful about how they perform their sit ups to avoid straining their neck. If your abdominal muscles are weak, it’s not uncommon to assist your sit up by using your momentum, which then leads you to pull on your neck which may end up with you experiencing some neck stiffness or even neck pain. However, neck pain is not the only possible side effect from too many sit ups. Have sit up enthusiasts considered that too many sit ups may also be placing them at risk of developing lower back pain?
How’s that you ask? Lower back pain? Well, it’s like this: Your body is a complex setup of biomechanical levers. One of the most important levers is your spine. Sit ups work the front part of your spine, pulling it forwards. Counteracting this movement are the spinal extensor muscles. Are you working them as well? Are the forces acting on your spine balanced? (Read my post on how lower back pain works Part 1)
Do you know where your spinal extensor muscles are? If you refer to the image below, you can see how long these muscles are and how far they extend along the length of the spine. Are you performing any spinal extensor muscle exercises in the gym? Do you know how?
If the muscles acting around your spine are unbalanced and your abs/ ‘6 pack’ is over worked in relation to the spinal extensor muscles, this may cause a constant slumping/slouching affect on your spine. Too much bending of your spine will cause an increase in the compressive and shearing forces through your spine and especially on your spinal discs. This may lead to premature wear and tear on these spinal discs (spinal cushions), which are in and of themselves weak in resisting bending and turning forces of the spine, too much of which may lead to lower back pain. Some research puts the incidence of lower back pain due to injuries of the spinal disc at 65% of all incidence of lower back pain.
Furthermore, performing sit ups as a strengthening exercise for the abs/’6 Pack’ shows a lack of understanding for the real function of the rectus abdominus (click here to read more). Sit ups are therefore not really functional and are also a high risk exercise for developing lower back pain. What then would be a better exercise to strengthen your abs/ ‘6 Pack’/ Rectus abdominus functionally? And would there be a way to simultaneously exercise the spinal extensor muscles and ensure balance of your spinal lever? The answer is a resounding yes. Read my post on using the plank as an exercise for more information.
Feel free to leave a question or comment. I would love to hear from you.
McGill S. (2010). Core Training: Evidence Translating to Better Performance and Injury Prevention. Strength and Conditioning Journal, 32 (3), 33-46.
Lower back pain is so common that 8 out of 10 us will experience it at some point in our lives. Any person who has experienced lower back pain can testify to how debilitating lower back pain is and how much it can negatively impact on your daily life, making common gestures like picking up a tissue off the floor, nearly impossible (read my post on how to strengthen your abs when you have lower back pain). Not only that, suffering from lower back pain is likely to make driving extremely difficult, if not even more painful (click here to read more about driving posture to reduce lower back pain). Sitting for long periods at the office or even trying to continue with your normal sport or recreational activities are also negatively impacted when lower back pain comes to call. All in all, one of the least desirable ailments (read my post on how picking up your children badly can cause lower back pain).
How then does lower back pain work? Understanding something is the first step in learning to deal with it better and hopefully to help find a way to reduce it’s impact in our lives.
Broadly speaking, your lower back pain will either be mechanical in nature or inflammatory (read about inflammatory lower back pain), or a combination of these.
When your lower back pain is mechanical in nature, this means that it relates to your biomechanics and to your musculoskeletal function. In other words, it’s how your bones, joints, muscles, nerves, blood vessels and discs are affected by your movements, postures and your rest, to either cause you lower back pain or relieve your lower back pain.
As some of you would know, often when you have lower back pain, some postures and movements are hell and others keep you sane and able to function.
It’s important to take note when this is the case. Some people suffering from lower back pain tend to take no notice of what aggravates or eases their lower back pain and they are missing out on very important information in helping to understand and treat their problem correctly and swiftly.
When your lower back pain is due to a mechanical cause, any movement such as sitting/rising/walking/bending/arching backwards/straightening your knee etc. will either increase, decrease or maintain the intensity of your lower back pain. This is because the mechanical forces created by these movements will have increased, decreased or remained constant on parts of your body tissues such as your spinal discs, facet joints, muscles or nerves.
In addition, you need to understand that different structures in the body are affected by different movements and postures and the forces that they apply. They are also affected by the type of damage that has occurred and how this causes the affected body tissue to respond to different mechanical forces.
Spinal discs for example are generally aggravated by bending and twisting and can be eased by arching backwards (in certain circumstances, in other circumstances the opposite is true – hence it’s important to see your OMT specialised Physio for assistance since they are especially trained to know these differences and much much more). On the other hand, generally speaking, your facet joints are aggravated by arching backwards but eased by bending and twisting. Thus, it’s really important to take note of which movements ease, aggravate or maintain your lower back pain. This information will help your OMT Physio get to the root of your problem faster.
Next time I will discuss chemical causes of lower back pain. Any comments? Please feel free to post them, I would love to hear from you.
We’ve said it before, but it bears repeating. Lower back pain is very very common. People who are at risk are office workers and drivers (in other words people who sit for long periods of time) as well as people such as nurses, manual workers in a factory/farm/warehouse setting (since they perform a lot of lifting and bending). In other words, most of us are at risk of developing lower back pain because of sitting for too long in a bad posture or because of lifting and bending poorly day in and day out in our jobs. That is why at least 80% of the world’s population will suffer from lower back pain at some point in their life.
To broadly understand your lower back pain, you need to think of it as mechanical in nature (read my post on mechanical lower back pain), or inflammatory, or a combination of these.
When your lower back pain is mainly as a result of chemicals in your body, this means that hormones and chemicals are circulating in the area of your pain, triggering a pain response from the brain. This can be due to trauma, arthritis, infections, physical pressure on a nerve or other tissue, or chronic pain syndrome (a very complex disorder involving the nervous and chemical systems of the body). Physically increasing the blood’s circulation through movement often aggravates lower back pain of an inflammatory nature. Too much rest (swelling and pressure build up when you rest too much if there is inflammation present) will also aggravate lower back pain in these circumstances.
Sometimes, lower back pain as a result of a mechanical problem can also result in an inflammatory response in the spine. When this occurs, this can really slow down your response to treatment, since the inflammation will need to settle, which normally takes anything between 3-7 days. If you keep aggravating your lower back pain (which many people do), you are liable to keep your inflammatory process active and delay healing further.
At other times, lower back pain of an inflammatory nature can leave scar tissue behind as a result of the inflammation, which in turn can cause mechanical problems for some body tissues such as a nerve impingement that again can result in lower back pain.
Another factor to bear in mind is that when your lower back pain is due to inflammation, anything than causes a change in your circulation will aggravate your lower back pain. This generally means that too much movement can increase your lower back pain because increased movement results in an increase in your circulation, which in turn increases the amount of chemicals causing your lower back pain to be present in the area of your injury. Too much rest also will cause an increase in your lower back pain, since when your circulation slows down, fluid moves out of your blood vessels and into the tissue surrounding it. This causes a pressure build up in your injured tissue which in turn increases your lower back pain. The key when you have lower back pain of an inflammatory nature is to do small amounts of movement often. Not too much movement and not too little. If you listen to your body, it will guide you to get the balance right.
Understanding what type of back problem you have is important to treat it properly. Make sure you have the correct person with enough expertise and medical knowledge to help you. OMT specialised physiotherapists are among the best people to help you resolve your back pain.
Do you have any questions or comments? Please take the time to post it, I would love to hear from you.