Back Pain Solutions: How to Help Yourself With Posture-Movement Therapy and Education.

Kodish BI. Pasadena, CA 91115-0490, Extensional Publishing, 2001, paperback, 318 pp, illus, ISBN:0-9700664-5-7, $20.

This book provides the tools that people with back pain can use to identify and modify posture and movement habits that may be contributing to their pain. The book is also appropriate for practitioners such as physical therapists, chiropractors, medical doctors, body workers, and movement educators who work with clients with back pain. The author uses mechanical diagnosis techniques (McKenzie approach), along with concepts of psychophysical education (Alexander technique) and general semantics, to teach solutions to back pain. The book focuses on the relationships among the head, neck, back, and the rest of the body.

In the first 3 chapters, the author introduces his concept of posture-movement education through the use of case examples. In chapter 4, concepts from the Alexander technique applicable to people with back pain are explained as ways to change habit patterns that may be contributing to the cycle of pain. The use of "inhibition," or stopping and taking the time to be aware of one's own posture, is one concept that Kodish describes as necessary for changing habits. A second concept follows inhibition when people "send directions" to themselves verbally for better use of the body. The book recommends that people with back pain use awareness of posture and directed intent to change posture and movement within their daily activities rather than using traditional stretching and strengthening exercises.

In chapter 5, the author reviews basic anatomy of joints, ligaments, tendons, muscles, nerves, and the spine from a didactic and functional perspective. Chapter 6 covers the neurophysiological aspects of pain. A hierarchy based on the perceptual control theory and intrinsic reorganizing systems is identified in chapter 7. The author suggests that this hierarchy, with the brain at the top of the pyramid and contraction of muscles as the final output, is helpful in identifying the processes of pain perception and pain behavior. The 11 levels within the hierarchy are: intensity, sensation, configuration, transition, event, relationship, category, sequence, program, principle, and system. Discrepancies between different levels of perception within the system result in error messages that, in turn, give messages for the system to reorganize and for the person to learn new postural behaviors and movements.

In chapter 8, Dr Kodish provides basic interview strategies for identifying the characteristics of pain perception and pain behavior. In addition, the reader is taught how to perform a movement-based back assessment derived from the McKenzie approach. The reader is provided with basic clinical decision-making skills for identifying mechanical diagnoses for back pain through repeated movement examinations. Beginning in chapter 9, the author presents his own model of the relationship between activity and back pain, a model that is based on the McKenzie approach, general semantics, the Alexander technique, and clinical experience. The model includes a conceptual framework for the process of self-perpetuated pain. This framework points to a person's interaction with the environment, response to the initial injury (including local soft tissue changes), sensory and perceptual changes, attitudes, beliefs and expectations, altered mobility, and changes in posture-movement patterns as contributing to vicious pain cycles.

In chapters 9 and 10, readers are educated in ways to identify and affect centralization and peripheralization of pain and symptoms by changing habits, postures, and faulty ,efforts. The reader is provided tools for documenting back pain, which include a pictorial body diagram for identifying type and location of pain, a visual analog scale, and a chart for identifying what makes the pain better or worse based on activity and time of day. The reader is taught the skills needed to identify the changes in posture and spinal movement that increase or improve their symptoms. The reader is also guided in making clinical decisions for safe progression through McKenzie exercises, including prone lying, prone on elbows, prone press-up, extension in standing, and flexion exercises. Illustrations of the exercises are provided.

In chapter 11, concepts of preferred body mechanics for distribution of forces during lifting type activities are presented. The author suggests that, for proper lifting, forces can be better distributed by folding at the hips with the knees bent, rather than bending throughout the spine. Awareness of lifting method, experiencing full stature frequently throughout the day, designing the environment to fit the needs of the individual and the task, and practicing postural variety are also emphasized as ways to improve body mechanics and function.

Chapter 12 is devoted to helping the reader to learn about body awareness. In chapter 13, the reader is guided through the decision-making process for what resting, sitting, and standing positions will be used to augment postural awareness and reorganization of posture towards full stature. Chapter 14 is geared towards educating the reader on the modification of constraints of the individual, home, and work environments to optimize full stature and change old posture-movement habits. Chapter 15 focuses on variability of the environment and self-awareness of posture and movement to reduce stress. Chapter 16 summarizes the previous chapters. An extensive bibliography is provided in the back of the book. The bibliography, however, consists mainly of references to books, newsletters, and non-refereed journals, with only a limited number of citations for refereed journal articles.

This book is potentially very helpful for patients with back pain who respond well to extension exercises. It is also a useful resource for clinicians who are interested in ways to empower their clients with back pain to help themselves. For practitioners with advanced experience in the McKenzie approach, the segments on posture and body awareness may be of interest.

Teresa M Miller, PT, MS
SUNY Downstate Medical Center
Brooklyn, NY

Mrs Miller is Clinical Assistant Professor at the Downstate Medical Center, a doctoral student at Temple University, and a certified Feldenkrais practitioner. Her research interests include motor control, motor learning, and management of chronic pain.