BACK INJURY BASICS Michael J. Mullin, ATC, PTA

1. BACK INJURY BASICSMichael J. Mullin, ATC, PTA Clinical Athletic Trainer Orthopaedic Athletic Performance Therapy Portland, ME

2. ANATOMY • Bones (26) • Vertebrae Sacrum • Cervical (7) -3 fused bones • Thoracic (12) Coccyx • Lumbar (5) -tailbone

3. Soft Tissue • Muscle / tendon • movers • stabilizers • Ligament • anterior longitudinal (hyperextension) • posterior longitudinal

4. Soft Tissue • Nerves • motor vs. sensory • brachial plexus, sciatic (sacral plexus) • Fascia • superficial--just below the skin, permits free movement • deep--which envelopes, invests, and separates muscles • a. irregular sheaths of collagen and elastin fibers • b. continuous with each other • c. separates muscles and structures while allowing independent function & absorbing shock

5. Intervertebral discs • Gelatinous structures separating the vertebral bodies • foremost function is to separate and allow for movement between the vertebral bodies • well-designed to withstand compression • poorly designed to withstand rotation or excessive bending

6. POSTURE • Alignment: natural spinal curves designed for shock absorption and to withstand compression

7. POSTURE • Ideal (plumb line) vs. reality • Kyphosis (“Hunchback”) • Lordosis (“gymnast”) • Flat-back (“nerd”) • Sway-back (“The Matrix”) • Scoliosis

8. SCOLIOSIS • lateral curvature (S- or C-curve) • most often corrects to midline • can be functional or structural • can be lifelong or adult onset • if a contributing factor to back pain, pain is most often present at the apex of the curve • adult onset can be due to chronic laxity (looseness) of the ligaments, osteoporosis, previous injury or surgery

9. Effect on musculature • Standing • regular standing posture vs. habitual patterns • Sitting • affected by position, chair, activity while sitting, time spent sitting • Activity • how much movement, kind of motion, repetition

10. Prevention of injury or reducing stress following injury • Work posture and modification • seated posture (head, arm pelvis and foot position) • computer, telephone, repetitive positioning • standing posture—weight shifting, locked joint positions • lifting, carrying, moving, repetitive positioning • postural “cues”—use pain, tightness or recognition of your back as a reminder • get up and move around regularly!!

11. Other considerations • Travel posture and modification • Day-to-day activities • Day-to-day activities • Getting adequate sleep • Psychosocial considerations

12. BACK PAIN • RISK FACTORS • Poor posture • Poor conditioning • Weakness • Stiffness • Faulty body mechanics • Poor work, sleep, or eating habits • Smoking • Psychosocial--bad attitude, stress, emotional • Other pathology (i.e. fibromyalgia, chronic fatigue or pain syndrome, osteoporosis)

13. Everyone’s favorite treatment works short term

14. WARNING SIGNS • Numbness into any limb (especially persistent) • Radicular symptoms (i.e. numbness/tingling down an extremity) • Persistent headaches (especially following traumatic neck injury) • Transient weakness • “Off-balance” (persistently) • Central, localized persistent back pain / especially if consistently reproduced with one specific movement • Persistent resting pain • Unexpected weight loss associated with back pain

15. INITIAL TREATMENT • Bedrest vs. measured activity • Medications • NSAID’S, acetominophen, ibuprofen • Modalities • ice (15-20 min.) regularly • heat--when stiff during day • analgesic balms • Physical therapy / exercise / pool therapy • Education

16. INITIAL TREATMENT • Traction (?) • Manipulation (?) • Alternative treatments • acupuncture / acupressure • massage / craniosacral / myofascial release • Pilates • psychological / psychosomatic • Supplements • glucosamine and chondroitin sulfate

17. We all want that magic pill

18. Exercise and back pain • Functional neutral positioning • Optimal position or range within which the spine functions most efficiently • Position where the spine is least symptomatic • Variable from patient to patient • Changes as symptoms and pathology changes • Imperative for patient to master and understand to successfully learn and utilize functional training • NEEDS TO BE MAINTAINED DURING ALL MOVEMENTS (i.e. activities of daily living, working out, back exercises)

19. Isolation of the deep abdominal muscles (transverse abdominus) • Designed for long-term use versus more superficial muscles (Type I vs. Type II muscle fibers) • Acts as the main active stabilizer for spine and pelvis control • Recruited by actively “drawing in” on abdominals like you are trying to pull your bellybutton up between your shoulder blades • NOT a pelvic tilt • Causes a co-contraction of the deep back stabilizers (multifidus) • NEEDS TO BE MAINTAINED DURING ALL MOVEMENTS

20. FLEXIBILITY • Joint / structural restrictions • hyper- or hypomobility of the sacrum or any of the vertebrae • structural vs. functional • Soft tissue tightness • hamstrings, hip flexors, hip rotators, lateral stabilizers • intercostals between the ribs • decreased shoulder motion • Stretching • static stretching vs. active or active-isolated

21. General considerations • All exercise must be PAIN-FREE • Start slowly and gradually increase as tolerated • Exercises should be performed evenly for the abdominals and back muscles • Weight bearing exercises need to be performed in order to increase the strength of the base of support • Some form of controlled cardiovascular exercise needs to be incorporated

22. TIPS & TRICKS • When in doubt, breathe out • Your back is your alarm clock • Chuck the wallet from the pocket • “Come on baby, don’t do the twist” • You’ve seen the pictures and heard it before, bend at the knees • It’s all in the abds. . .

23. MOST COMMON CAUSES OF POOR POSTURE AND THEIR SOLUTIONS • Forgetfulness--Let’s face it, the main reason most people cannot maintain good posture is forgetfulness. Unless someone is in pain and is able to use that as their reminder, people just do not think of it often enough.

24. SOLUTION: • Use a Reminder--Pick something that you think of regularly during the day--your spouse, your children, driving, every time the phone rings--and use that as your “alarm clock” to remind yourself to correct your posture. The more often good posture is practiced, the easier it is to maintain, the more natural and comfortable it feels--and it makes up for the times which you forget.

25. CAUSE: • Lack of Understanding--Most people do not truly have a thorough understanding of proper postural positioning. They view it as a “military-style” posture by thrusting their shoulders back, or straighten up through their mid-back and forget the head and neck.

26. SOLUTION: • Use Your Pelvis and Abdominals-There are two keys to proper posture--enough mobility through the pelvis, and a good idea of what to tighten through the abdominals. Start by sitting up straight in a chair with your feet planted or lying on your back on the floor with your knees bent. Place your hands on your hips so you can monitor hip motion, then start by tilting your hips forward like you are arching your back, and hold for 3 seconds. Then tilt them back and up by pulling up on your deep abdominal muscles and hold for 3 seconds. Do this 5 or 10 times, then find what is roughly midway between both stopping points. This is where you want to be. If you think about your deepest abdominal muscles holding this position, you will not only find it easier to maintain, but an almost automatic tension reliever.

27. CAUSE: • Work--Whether the job is at a desk, performing manual labor, traveling long distances, or performing surgery, it all takes its toll on our bodies. We have a tendency to tighten up into positions which we are regularly in and this eventually causes a breakdown somewhere along that chain.

28. SOLUTION: • Change Your Ergonomics--Both physically and structurally. Physically by modifying your work environment to be more movement friendly, and structurally by the way the tasks are performed. Whatever the job is that you do, you need to think of putting yourself in the optimal position to perform the task. Desk and keyboard height, repetitious tasks, and heavy lifting all need to be evaluated to make sure that the work station and environment do not predispose or exacerbate injuries.

29. CAUSE: • Deconditioned--With today’s hectic world and pace, people have been finding it increasingly difficult to maintain some form of regular exercise. This not only prevents the release of the much needed stress-relieving endorphins, but it also contributes to weakening of the muscles, bones and joints of the body and reducing the amount of good synovial fluid into the intervertebral discs.

30. SOLUTION: • Exercise--You are only as good in your personal and professional life as you feel. When the body does not get some form of regular exercise or activity, things just do not work as well. You never let your car go much more then a few days without running it, so why should you think that the body is any different. Any combination of home exercise programs, pool workouts, outdoor exercise, gym routines, yoga, or Pilates will work. Just make it consistent.

31. CAUSE: • Anatomical--Some of us are born with, develop, or acquire physical conditions which make what would be considered good posture extremely difficult. Mother Nature can be cruel sometimes.

32. SOLUTION: • Treatment—First, don’t blame it on your mom. There are a number of different quality practitioners such as physical therapists, physiatrists, and chiropractors, which can help to treat individual conditions. If the system is not functioning properly, forcing it will not help. The longer people wait to seek treatment or do not maintain their recommended routine, then the worse the condition will get.