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When--and how--to exercise away back pain.

Up to 80 percent of us will experience a form of low back pain at some point in our lives. Americans spend at least $50 billion each year on low back pain, which is well documented as the most common cause of job-related disability and a leading contributor to missed work. In fact, back pain is the second most common neurological ailment in the U.S.--only headache is more common. Fortunately, most occurrences of low back pain go away within a few days. Others take much longer to resolve or lead to more serious conditions. Recurrence rates are disconcertingly high, estimated at a rate of about 50 percent in the 12 months following an episode.

Acute or short-term low back pain generally lasts from a few days to a few weeks. Not all back pain is neurologic in origin; most acute back pain is in fact mechanical or musculoskeletal in nature, the result of trauma to the muscles of the lower back or of a bone disorder such as arthritis. Pain from trauma may be caused by a sports injury, a sudden jolt such as a car accident, or other stress on spinal bones and tissues.

Muscles, bones, and nerves

Musculoskeletal back pain, such as from overreaching or heavy lifting, often results in a sprain, strain, or spasm in one of the muscles or ligaments of the back. But back pain can exacerbate both the musculoskeletal system and the nervous system simultaneously: if the spine becomes overly compressed (essentially a skeletal problem), a disc may rupture or bulge outward. This rupture may put pressure on one of the more than 50 nerves rooted to the spinal cord that control body movements and transmit signals from the body to the brain (a neurological problem). When these nerve roots become compressed or irritated, back pain results.

Pain that persists for more than three months is considered chronic. It is often progressive and the cause can be difficult to determine. Generally, as people age, bone strength and muscle elasticity and tone tend to decrease. The discs begin to lose fluid and flexibility, which decreases their ability to cushion the vertebrae.

Other degenerative conditions that can cause serious low back pain include disc disease, osteoporosis, viral infections, irritation to joints, or congenital abnormalities in the spine. Obesity, smoking, weight gain during pregnancy, stress, poor physical condition, poor posture, and poor sleeping position also may contribute to low back pain. Additionally, scar tissue created when the injured back heals itself does not have the strength or flexibility of normal tissue. Build up of scar tissue from repeated injuries eventually weakens the back and can lead to more serious injury.

Sedentarism strikes again

Back pain occurs most often between ages 30 and 50, due in part to the aging process but also as a result of a sedentary lifestyle with too little exercise. In one influential randomized controlled trial that looked at the outcomes and costs of exercise as an intervention for back pain sufferers, researchers found that a general exercise program, aimed at increasing individuals' confidence in the use of their spine and overcoming the fear of pain during physical activity, was highly effective for patients with chronic back pain. Too little exercise, then, can be both a cause of initial back pain onset and a missed opportunity for significant therapeutic improvement over the long haul.

The 187 subjects, ages 18 to 60 years, were either assigned whole-body, general strengthening exercise classes for all main muscle groups (including stretching, relaxation sessions, low-impact aerobics, and brief education on back care) or to a non-exercise class group that continued primary care. In some instances, primary care included physical therapy and even prescription of stretching and/or strengthening exercises. The hourlong, twice-a-week classes used no special equipment and simply encouraged normal movement of the spine.

After six months and then again at one year, the intervention group showed significantly greater improvement in the disability questionnaire score and in the Aberdeen back pain scale. They reported only 378 days off work compared with 607 in the control group. Better still, the intervention group used far fewer healthcare resources.

If exercise class can be shown to be more clinically effective than traditional general practitioner management, and also be more cost effective, clearly this treatment modality--which in this case did not even single out the back specifically--deserves a great deal of consideration.

Exercise, any exercise ... within reason

A routine of back-healthy activities may include stretching exercises, swimming, walking, and movement therapy to improve coordination and develop proper posture and muscle balance. Yoga is another way to gently stretch muscles and ease pain. Any mild discomfort felt at the start of these exercises should disappear as muscles become stronger. But if pain is more than mild and lasts more than 15 minutes during exercise, you should stop exercising and contact a doctor.

The studies conducted to date have not identified any particular type or level of exercise that works better than others for preventing low back pain. However, the data suggest that people who exercise regularly, compared with those who do not, tend to have fewer recurrences of back pain over time. The fact that one type of exercise may not be significantly better than another might even be seen as an asset to this type of intervention, as it allows patients the flexibility to adopt whichever general exercise regimen suits their specific lifestyle, within a reasonable range.

Three easy stretches

More back-specific stretching and strengthening exercises can help to prevent flare-ups of back pain related to muscle strains and sprains. If you have low back pain due to a muscle strain, you might consider performing these three exercises, ideally every day, after the flare-up subsides (and your doctor says it's safe). Do take it slow, and stop if it hurts:

1. Lying on the floor on your back (supine position), starting with the knees bent, pull one knee to your chest and hold the stretched position for 5 to 10 seconds. Alternate sides; repeat 5 to 10 times each.

2. From the supine position, starting with the knees bent, pull both knees to your chest and hold the stretched position for 5 to 10 seconds. Repeat 5 to 10 times.

3. From the supine position, starting with the knees bent, flatten your lower back to the bed or floor. Hold the back flat for 5 to 10 seconds. Repeat 10 times.

Low back pain due to muscle strain or muscle spasm is amenable to exercise, but if the pain traces to a problem in the spine, approach exercise more cautiously. One common warning sign of a spine-related problem is sciatica, or pain that radiates from the back down into the leg. The pain may be accompanied by a tingling pins-and-needles sensation. If you have sciatica, don't begin a new exercise program without speaking to a doctor.

Seek medical attention if...

Less commonly, low back pain can be a red flag that warrants immediate medical attention if it takes any of these forms:

* back pain with fever

* pain that does not improve or worsens

* numbness in the groin

* loss of bladder or bowel control

* leg weakness

* inability to find a comfortable sitting or sleeping position during episodes of back pain.

And when back pain is severe, remain up and around to the extent possible. Prolonged bed rest is not good during a bout of severe back pain, but neither is rushing too soon and too intensely into stretching and strengthening exercises. You are not going to be able to embrace an exercise routine the very next day after a strain. Furthermore, resume your normal activities as soon as possible, but avoid lifting heavy weight and engaging in physical activities that exert sudden stresses on your back, like tennis or yard work. When the severe pain subsides, gradually begin daily, gentle exercises to stretch and strengthen the muscles that support the lumbar spine. This will help stave off that 50 percent recidivism rate for back injuries: stronger and more flexible muscles are after all less prone to reinjury.

See an opportunity

A bout of low back pain can even have a silver lining, in the form of a wake-up call. As Harvard Medical School professor of orthopedic surgery Jeffrey Katz, MD, says in the August issue of Harvard Men's Health Watch, "An episode of acute low back pain is a call to action for people who are simply not exercisers. It is a good time to make a commitment to exercise when you are starting to feel a bit better--typically in a few weeks. You could have a lower risk of flare-ups over the subsequent year."

To that end, why not make low back pain sufferers' general fitness exercise classes much more widely available, in lieu of less effective and more costly treatment options? After all, any treatment that encourages, and actually facilitates, normal movement of the spine has clearly got your back.

NIH, National Institute of Neurological Disorders and Stroke, "Low Back Pain Fact Sheet," updated May 2013, http://www.ninds.nih.gov/disorders/backpain/detailbackpain.htm

BMJ 1999;319:279, http://www.bmj.com/content/319/7205/279

Harvard Men's Health Watch, Aug. 2013, http://tinyurl.com/lfffzg4
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Publication:Running & FitNews
Geographic Code:1USA
Date:Jul 1, 2013
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