Bad habits such as the way you stand (posture) or the way you position yourself (body mechanics) can contribute to the onset of low back pain.  Poor posture and body mechanics change the optimal alignment of the spine over time leading to a process of degeneration.  Often, the process can and will result in weakened discs, inflamed joints, irritated nerves, and painfully tight overworked muscles.  Maintaining proper posture during lying, sitting and standing positions has a significant affect on reducing the stress and strain on the spine which are associated with pain and injury.  Learning how to move properly during common daily activities such as bending, lifting, turning, and reaching is also critical in preventing low back pain.  Many of you may have experienced the ill effects of poor body mechanics during activities such as moving furniture, lifting children, or snow shoveling.

A healthy back needs to be strong and flexible.  Daily exercises aimed at stretching and strengthening muscles and maintaining the flexibility of your spine will help to accomplish this.  One highly recommended exercise for your back is regular walking.

There are many other useful self care tips and techniques that can be learned to keep your back healthy.  Here are a few: maintain an optimal body weight, wear the right shoes, shift positions often at home and work, choose the right bed, use lumbar support for sitting, self-massage, or better yet get someone else to give you a massage.

A physical therapist can help develop an exercise program that is right for you while teaching you the skills you need to move safely and keep your back healthy.  If you are interested in taking care of your back to prevent the onset of low back pain or to address a current back pain problem you should consider seeing a trained physical therapist.

The long term effects of poor sitting posture have been associated with numerous painful conditions relating to the function of muscles, joints, ligaments, nerves, connective tissue, circulation, respiration, and digestion. Common associated diagnosed conditions include temporomandibular joint dysfunction, headaches, neck pain, shoulder pain, repetitive strain injuries, mid and low back pain, thoracic outlet syndrome, and myofascial pain syndrome. More importantly, poor sitting posture may adversely affect activities of daily living and overall energy level at work and home.

The concept that there is a single ideal posture is misleading. This idea does not take into account that people are proportioned differently or for example the multiple positions a worker needs to sustain to accomplish a task in varying situations. Factors that influence our postures include the environment surrounding us, our personal habits and attitudes at a certain point in time. There is no “perfect posture.” Posture is dynamic. Functionally, our bodies are reacting to and working against gravity and other stresses to maintain balance. Good sitting posture maintains the three normal curvatures of the spine. The lumbar (lower back), thoracic (mid-back), and cervical (neck) transform the spine into a flexible unit allowing the body and head to be erect with minimal muscular effort.

Prolonged static sitting position will eventually lead to feelings of stiffness, soreness, achiness and pain as body tissues become overloaded. The most commonly seen improper sitting posture is “slouching”; characterized by a rounded lower back, humped upper back, rounded shoulders, and a forward head position. The resultant alignment leads to biomechanical dysfunctions of the spine and the extremities, which include muscle imbalances, connective tissue restrictions, altered mechanics of the shoulder and spinal joints, increased vertebral disc compression and narrowing of the space in which arteries and nerves pass. In essence, poor posture allows one to become vulnerable to injury and is one of the factors which hinders healing and adequate resolution of associated painful conditions.

In most cases, it is not too late to experience the positive outcomes of improving one’s posture.  Physical therapy evaluations incorporate a postural assessment to define the severity of the postural problem, to identify contributing factors, and to recognize the possible relationship to someone’s given pain and dysfunction. Treatment of postural dysfunctions may involve regaining the normal length of shortened muscles, mobilizing stiff extremity and spinal joints, strength and endurance training of postural muscles, addressing environmental/ergonomic factors, and education of postural awareness and correction. Awareness is the key to the success of postural reeducation. Just like your body has adapted to poor posture over a number of years, you can allow your body to adapt once again to its natural structural state.

Well much of the country has experienced record snowfall this season and of course with that comes digging out of the snow.  Snow shoveling can contribute to a host of injuries to the spine, shoulders and muscles of the body.  Most of the problems are as a result of excessive bending and twisting while carrying a heavy load.  Here are some tips to avoid pain and injury from shoveling snow.

The Basics:

Think of snow shoveling as a form of exercise, so as with any exercise prepare your body for what you are about to do.

• Don’t begin shoveling snow after eating, smoking or consuming caffeinated beverages.
• Warm-up your body with some gentle movements and stretches as you would before any exercise.
• Dress appropriately.  Ensure that you have good footwear to avoid unnecessary slips and falls, dress in layers, wear gloves that will keep the hands warm and dry, and wear a hat the will keep your head dry.
• Stay hydrated.  Drink plenty of water before, during and after.
• Stop if you are hurting or you feel pain of any kind.  Don’t make a problem worse by trying to work through the pain.  The exception is the feeling of muscle fatigue, which is to be expected.
• Take plenty of breaks.  Don’t try to finish the job all at once.  It’s better to divide the work in several segments, especially if you are dealing with large amounts of snow.
• Know Heart Attack Warning Signs: chest discomfort, discomfort in other areas of the upper body, shortness of breath with or without chest discomfort, breaking out in a cold sweat, nausea or lightheadedness.  Please call for help immediately if you are experiencing these symptoms.

The Form:

Proper body mechanics is critical to avoiding pain and injury from snow shoveling.

• Use the right shovel.  Ergonomic shovels that have a curved shaft allow for better leverage and are easier on the body.  Plastic shovels are typically lighter than metal ones.
• Proper grip is important.  Don’t keep your hands too close together.  Placing your hands further apart improves the leverage, which will allow you to work more efficiently.
• Maintain proper spine alignment.  It is critical that you keep your back straight and head in line with your spine.  Your ear, shoulder and hip should always stay in line.  To attain proper spinal alignment while bending, you should bend your knees, stick your hips back, keep your back straight and tuck your chin slightly in.
• To shovel snow: keep feet apart, bend the knees, lift the shovel by straightening your knees and not by straightening your back.  If you need to move the snow, walk your feet to where you would like to dump the snow.  Never bend at the waist and twist to move the snow to the side.  Never thrown snow over your shoulder.
• Push whenever you can.  Pushing the shovel with one leg in front of the other, knees slightly bent and back straight is always better than lifting the snow.
• Lighten the load.  Don’t try to move heavy amounts of snow.  It’s better to minimize the load.

Remember to take frequent breaks and stop if you feel pain.

If by chance you do end up injuring yourself, consult a physical therapist for a consultation so that your pain and functional limitations are kept to a minimum.

BJ from from Wichita State University won the top prize of $1000 in Evidence In Motion’s 30 Second Elevator Pitch 2008 Competition!

The International Headache Society has classified hundreds of different types of headaches into two categories: primary headaches and secondary headaches.  Primary headaches are the most common headache type and have a single cause.  They include migraine, tension-type, cluster and others. Secondary headaches are classified according to their causes.  Examples of secondary headaches are headaches attributed to temporomandibular joint (TMJ) disorders and cervicogenic headaches, which are attributed to mechanical disorders of the neck.  Both are treated by various clinicians including osteopaths, dentists, chiropractors, massage therapists, and physical therapists.

Sources of headaches are often a combination of factors, including musculoskeletal, psychological, neurovascular, nutritional and chemical imbalances in the brain.  Some headaches relate to or are indicative of a disease process; some are life threatening and others benign.  Thus, a thorough medical evaluation is necessary with any onset of a new or ongoing headache.  Most researchers agree that there is a musculoskeletal component in tension-type, cervicogenic, and TMJ disorder related headaches.

A thorough physical therapy examination attempts to determine the type of headache and to define the neuromusculoskeletal factors contributing to it.  Muscle tension, joint dysfunction of the neck and jaw, poor posture and stress are factors that can be addressed and treated by a skilled physical therapist trained in manual therapy.

The muscles of the face, head, neck and may contain tight bands and contraction knots called myofascial trigger points.  Trigger points found in these muscles typically refer pain to the head, causing headaches.  Manual physical therapy addressing muscle tension involves the release of those trigger points, stretching the involved muscle and soft tissue, and restoring normal muscle function.  Trigger point release can be accomplished by manual techniques and dry-needling.  Dry-needling is a technique in which a thin acupuncture needle is used to deactivate the trigger points and proves to be highly effective.

Dysfunction in the spinal joints of the upper neck and of the TMJ can directly cause headaches or can trigger migraine or tension-type headaches.  Treatment of spine dysfunction may include mobilization/manipulation of the spine or jaw and the performance of stabilization exercises of the neck and shoulder girdle.  In the case of TMJ dysfunction, referral to a dentist may be indicated for splint therapy and other dental interventions.

Prolonged poor posture of the head, neck and shoulders leads to the overloading of muscles, which in turn results in the development of trigger points and altered mechanics of the spine and TMJ.  Physical therapy treatment may include education for postural correction and prescription of a postural strengthening program.  In cases where stress is a contributing factor — which it almost always is — treatment would include education with relaxation and breathing techniques.

If you are a headache sufferer and you are looking for a way to manage your headaches beyond using medication, talk to a manually trained physical therapist about possible conservative treatment options.

ALEXANDRIA, VA, February 9, 2007 — The American Physical Therapy Association (APTA) has endorsed the BackTpack®, an innovative carrying system that uses the vertical force of gravity to ensure proper alignment of the skeleton, developed by physical therapist and APTA member Marilyn Miller von Foerster, PT.

School student wearing the BackTpack.

“Physical therapists are acutely aware of the postural problems children face when trying to adapt to a heavy load, such as arching the back, bending forward, or leaning to one side,” said R Scott Ward, PT, PhD, president of APTA. “The backpack was designed so that children and adults may be better able to maintain correct posture while carrying a load,” Ward said. “We are pleased to be able to endorse a product that can contribute to the effort to prevent back pain and improve balance.”

The BackTpack® is available in sizes for children and adults from 4′0″ to 6′3″ tall. Its vertical design allows for proper posture, and the side pockets and cell phone and pen pockets offer better balance, easy accessibility, and overall convenience when standing, sitting, or walking.

“It is crucial for lifelong spinal health to practice good posture habits, especially during the years of rapid and permanent skeletal development,” Miller von Foerster noted. “I am pleased to be able to use my education and training as a physical therapist in this way and to offer the BackTpack® as a new tool to help people of all ages achieve improved posture and reduce the incidence of back pain.”

Miller von Foerster, who has helped patients with back conditions for 35 years, is a native Oregonian and received degrees from the University of Oregon, Duke University School of Physical Therapy, and San Francisco State University. For more information on the BackTpack®, visit www.backtpack.com.

Physical therapists (PTs) are health care professionals who diagnose and treat individuals of all ages, from newborns to the elderly, who have medical problems or other health-related conditions that limit their abilities to move and perform functional activities in their daily lives. PTs examine each individual and develop a plan of care using treatment techniques to promote the ability to move, reduce pain, restore function, and prevent disability.

The American Physical Therapy Association (www.apta.org) is a national organization representing nearly 70,000 physical therapists, physical therapist assistants, and students nationwide. Its goal is to foster advancements in physical therapist education, practice, and research. Consumers can access “Find a PT” to find a physical therapist in their area, as well as physical therapy news and information, at www.apta.org/consumer. For more information about the meaning of APTA’s product endorsement, visit www.apta.org/productendorsement.

Available at ISSA PHYSICAL THERAPY in a number of different styles, sizes and colors.

The BackTpack is perferct for traveling.

Great for parents on the go.

AAOMPT Executive Committee Position Statement:

It is the Position of the AAOMPT Executive Committee that dry needling is within the scope of physical therapist practice.

Support Statement:

Dry needling is a neurophysiological evidence-based treatment technique that requires effective manual assessment of the neuromuscular system.  Physical therapists are well trained to utilize dry needling in conjunction with manual physical therapy interventions.  Research supports that dry needling improves pain control, reduces muscle tension, normalizes biochemical and electrical dysfunction of motor endplates, and facilitates an accelerated return to active rehabilitation.

This has been approved as an official position of the AAOMPT Executive Committee.  In October at the AAOMPT Annual Conference in Washington, DC the AAOMPT Membership will have the opportunity to determine if this should be accepted as a Position of the AAOMPT Membership.  As an FYI, this process is very similar to how the APTA process works wherein, there are official positions of the APTA Board and official positions of the Association that come from the APTA House of Delegates.  In some cases the APTA Board will pass a position statement and in time the House of Delegates may pass the same or similar position statement.

Symptomatic lumbar degenerative disc disease develops when a disc weakens (often due to repetitive strain), is injured, or deteriorates from aging. As a result, the disc is unable to hold the vertebrae as it should and the lack of stability can cause back pain.

The review details the different treatment methods for symptomatic lumbar degenerative disc disease, including physical therapy with the use of nonsteroidal anti-inflammatory drugs (NSAIDs), and concludes that, in most patients with low back pain, symptoms resolve without surgical intervention. The review also concludes that physical therapy and nonsteroidal anti-inflammatory drugs are the “cornerstones” of non-surgical treatment.

Physical therapist intervention includes strengthening of core muscle groups, including the abdominal wall and lumbar musculature, which can have positive effects in patients with this condition. According to APTA spokesperson Julie Fritz, PT, PhD, ATC, clinical outcomes research scientist at Salt Lake City’s Intermountain Healthcare and associate professor at the University of Utah, physical therapists have several treatment options that can help patients with LBP whether due to degenerative disc disease or a variety of other causes.

Exercise and manual therapy including spinal manipulation, have been shown to benefit many patients.2, 3. In addition, patient education to remain active and use appropriate body mechanics is beneficial. Physical therapists are trained to identify which of these treatment strategies will be most effective for an individual patient, which further improves the effectiveness of care.

In previous systematic reviews of the literature, it was found that exercise has been shown to improve function and decrease pain in adult patients with chronic LBP and that physical therapy was beneficial for the treatment of acute LBP.2, 3 In another systematic review, NSAIDs were found to provide LBP patients with short-term symptomatic relief.4

“Receiving care from a licensed physical therapist can further improve the odds that a patient can maintain their quality of life and avoid surgery,” said Fritz. In addition to building the core muscle groups, hands-on therapy to mobilize the spine has been shown to be particularly effective. 5, 6  “Spinal manipulation can be an important component of physical therapist treatment for low back pain. Supplementing exercise with spinal manipulation is also beneficial for many patients.”

Physical therapists can help patients develop a safe and effective exercise program that is tailored to an individual’s specific needs and goals. “Surgery should be the last option, but too often patients think of surgery as a cure all and are eager to embark on it,” said Luke Madigan, MD, an attending physician at Knoxville Orthopaedic Clinic, Knoxville, TN, and the lead author of the literature review.

Physical therapists are highly-educated, licensed health care professionals who can help patients reduce pain and improve or restore mobility – in many cases without expensive surgery or the side effects of prescription medications. APTA represents more than 70,000 physical therapists, physical therapist assistants, and students of physical therapy nationwide. Its purpose is to improve the health and quality of life of individuals through the advancement of physical therapist practice. In most states, patients can make an appointment directly with a physical therapist, without a physician referral. Learn more about conditions physical therapists can treat and find a physical therapist in your area at www.moveforwardpt.com.

1Andersson GB: Epidemiological features of chronic low back pain. Lancet 1999; 354:581-585.

2Hayden JA, van Tulder MW, Malmivaara A, Koes BW: Exercise therapy for the treatment of non-specific low back pain. Cochrane Database Syst Rev. 2005;(3):CD000335.

3Assendelft WJ, Morton SC, Yu EI, Suttorp MJ, Shekelle PG: Spinal manipulative therapy for low back pain. Cochrane Database Syst Rev. 2004;(1):CD000447.

4vanTulder MW, Scholten RJ, Koes BW, Deyo RA: Nonsteroidal anti-inflammatory drugs for low back pain: a systematic review within the framework of the Cochrane collaboration back review group Cochrane review. Spine 2000:25:2501-2513.

5Childs JD, Fritz JM, Flynn TW, Irrgang JJ, Johnson KK, Maikowski GR, Delitto A: A clinical prediction rule to identify patients with low back pain most likely to benefit from spinal manipulation: a validation study. Ann Intern Med. 2004; 141(12):920-928.

6Chou R, Huffman LH: Nonpharmacologic therapies for acute and chronic low back pain: a review of the evidence for an American Pain Society/American College of Physicians clinical practice guideline.; American Pain Society; American College of Physicians; Ann Intern Med. 2007; 147(7):492-504.

[Last updated: 02/23/09 | Contact: public-relations@apta.org]

Their findings about the potentially important “scaffolding” role of this poorly understood muscle has been published on line in advance of the January issue of the Journal of Bone and Joint Surgery.
“The multifidus muscle was formerly thought to be relatively unimportant based on its fairly small size,” said Richard L. Lieber, Ph.D., Professor and Vice Chair of UC San Diego’s Department of Orthopedic Surgery and Director of the National Center for Skeletal Muscle Rehabilitation Research, based at UC San Diego. Lieber is also Senior Research Career Scientist at the Veterans Affairs San Diego Health System. “Our research shows that it’s actually the strongest muscle in the back because of its unique design. It’s like a long, skinny pencil packed with millions of tiny fibers.”

The researchers discovered that the multifidus has a unique packing design consisting of short fibers arranged within rods, and that these fibers are stiffer than any other in the body. Using laser diffraction methods that they developed to measure muscle internal properties during back surgery, they demonstrated that the multifidus’ unique design serves a critical function as a stabilizer of the lumbar spine. These findings could have implications for surgery, according to Steven R. Garfin, M.D., Professor and Chair of UCSD’s Department of Orthopaedic Surgery.

“It is important to identify what each individual muscle does, and this is just a start, showing that the multifidus contributes significantly to spinal stabilization,” said Garfin. “The more we know about what muscles do, the better we can devise therapeutic interventions such as physical therapy to target specific muscles.”

Garfin explained that currently surgery to treat spinal disorders could actually disrupt the multifidus muscle, which could lead to decreased stabilization and lower back pain. Minimally invasive spine surgery techniques strive to minimize surgical trauma to these muscles in order to best preserve their function.

The lower back, or lumbar spine, can be vulnerable to many pain-causing injuries or disorders because the lumbar vertebrae carry the most body weight and are subject to the most force and stress along the spine. Muscular instability is a risk factor in many injuries and consequent chronic lower back pain, according to Lieber. “The multifidus back muscle keeps us vertical and takes pressure off the discs,” said Lieber. “When muscle function is poor due to back problems, support is lost.”

He explained that many muscles get weaker as they are extended. But the researchers discovered that, unlike all other muscles, the multifidus actually becomes stronger as it lengthens, when the spine flexes.
“The length of the sarcomere—the structure within the muscle cell where filaments overlap to produce the movements required for muscle contraction—is shorter in the multifidus than in any other muscle cell,” explained study’s first author Samuel R. Ward, P.T., Ph.D., Assistant Professor of Radiology at UC San Diego School of Medicine. “But as it gets longer, for instance as a person leans forward, the multifidus actually strengthens.”

Contributing authors to the study include UCSD researchers Choll W. Kim, M.D., Ph.D., Carolyn M. Eng, B.S., Lionel J. Gottschalk, B.S.; and Akhito Tomiya, M.D., Ph.D. Tohoku University School of Medicine, Sendai, Japan. Research was supported by the Department of Veterans Affairs Rehabilitation, Research and Development; the National Institutes of Health and DePuy Spine of Raynham, MA.
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Adapted from materials provided by University of California – San Diego, via EurekAlert!, a service of AAAS.

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A Physical Therapist’s Perspective:

This report should be of interest to any physcial therapist that treats low back conditions because it provides evidence of the role that the multifidus muscle plays in stabilization of the spine. Although, I have issue with the statement that “the multifidus muscle was formerly thought to be realtively unimportant based on it’s fairly small size”. Physical therapy researchers discovered over a decade ago the importance of the multifidus muscle in spine stability and its relation to low back pain. For this reason many physical therapists have advocated the importance of proper rehabilitation following any lumbar spine surgery that disrupts the multifidus muscle.  In addition, much of recurrent and chronic low back pain can be attributed to spinal instability. Thus, there has been much focus in the clinical field of physical therapy to perform exercises that retrain the multifidus in conjuciton with the transverse abdominus and pelvic floor muscles. To read more about the role of motor control exercises for spine related problems read this news release- Report Shows Motor Control Exercises Reduce Persistent Low Back Pain

Tamer S. Issa, PT, DPT, OCS