Dr. Mark Amerasinghe

Dr. Mark Amerasinghe

Monday, April 21, 2014


Backache: You can prevent this common but disabling problem’
[This two part article was first published on 19 July(Part1) and the followint August(Part 2) 2009, in the Sunday Times, Sri Lanka]

Part one:
Getting to know your anatomy to understand simple yet vital posture tips
By Dr. Mark Amerasinghe

 Here are a few suggestions that will help avoid backache and prevent a recurrence of pain in those who have had the problem.
Prevention is based on the recognition that backache is commonly a result of faulty posture throughout the day and strains, particularly during our activities of daily living. Some important anatomical facts will help explain the rationale of the advice given below.
The low-back which bears the weight of the head, chest and upper limbs, as well as the stresses of walking, jumping and running, transmitted to this vulnerable region through the lower limbs via the pelvis, is hollowed out. This is because the spine in this region is curved and projects forwards. The vertebrae which together form the spine consist of a strong block of bone (the body) in front and weak arched struts of bone at the back, hollowed out to accommodate the spinal cord, from which the spinal nerves arise.
Between the very strong bodies which are built to withstand weight, are the crepe rubber-like strong intervertebral discs. The more curved the spine in this region, the more marked the hollow of the low-back[the lumbar lordosis] and the greater the strain on the back part of the disc and the weak arches.
Furthermore, just as the discs are firmly attached to the bodies of the vertebrae by strong ligaments which prevent them actually 'slipping' in relation to each other, the arches are connected to each other by elastic ligaments which allow movement between the vertebrae, while more fibrous ligaments prevent excessive movement. The movement between the arches occurs at tiny joints between small slivers of bone projecting from the arches. These joints permit smooth movement between the arches and like the bigger joints such as the knee joint, if subjected to excessive or abnormal stresses, can swell up.
 These tiny joints form the back wall of the opening between the arches of two adjacent vertbrae. The spinal nerves leave the spine through these openings [the intervertebral foramina].Hence, a spinal nerve when leaving the spine can be pressed upon from the front by a protruded/prolapsed disc or irritated from behind by a strained and swollen joint. Strain or sprain of these joints or injury to the associated ligaments is likely to occur as a result of bad posture, particularly during activity.

The more curved the low-back, the greater the shift of stresses to the back and the greater the chance of straining the ligaments and tiny joints. Furthermore, the weight of the upper part of the body and the stresses of activity are thrown more on the back part of the disc which is thinner and weaker than the front part.

The flatter the low-back, the less the forward curvature of the spine, the less the strain on the back part of the spine and the more evenly is the weight distributed throughout the disc, thus relieving excessive pressure on the back part - the vulnerable part.

Strong abdominal muscles connect the lower chest with the front part of the bony pelvis which transmits stresses from the lower limbs to the low-back and vice-versa. Since these muscles are in front, when they are well developed or further tightened, they pull strongly on the front part of the pelvis tilting it upwards so that the forward curve of the spine is reduced.

The hollow of the low-back is reduced and even flattened out completely. So tucking your tummy in , by tightening (contracting) the abdominal muscles, flattens the low-back and reduces the stresses and strains on it. (The so-called middle-age spread with the resulting prominent protruding tummy is often due more to lax and flabby abdominal muscles than to the accumulation of fat.)

Simple advice for daily activities
Sitting – whenever possible, sit in a chair with a firm, upright back-rest which permits sitting straight. The trunk should be at right angles to the thighs and be pressed firmly against the chair back, in such a manner that the hollow of the back is flattened out as much as possible. To achieve this desirable position it is necessary to sit with your knees bent at a right angle, leaving a space of a hand's breadth between the edge of the seat and the back of the calf. In this position tuck your tummy in by tightening your abdominal muscles.

When you perform this action as described, you will actually feel that you have increased in height. In fact you have, because you have converted a hollow low-back into a straight one. Arm rests are helpful in achieving the correct sitting posture.

When getting up – draw your feet back, under the front edge of the seat, bend your straight trunk forwards at the hips so that it is poised over your feet, which serve as a firm base for the next move. Press your flat feet firmly down on the floor, while placing your hands on the arms or the sides of the chair and push yourself up, without twisting your body. The major push comes from the pressure of the feet on the ground.

The above posture is very important to get used to, because the majority of sedentary workers spend so much of their waking hours in the seated position. It should be possible to use a suitable straight-backed chair in the workplace. But, unfortunately, sitting-room chairs are more often than not, designed for beauty and elegance and not for function, without danger to one's back, They tend to have sloping backs and sloping seats which are so deep that when you sit well back, your back is not upright and your knees cannot be bent to a right angle.

When getting out of a chair of this type, move well forward so that your buttocks are close to the edge of the seat, assume the straight back posture and push up as described above. Do not wiggle out of the chair twisting your back in the process. This way of sitting and getting up may at first be difficult to get used to, but it is worth the initial effort.

When you get into the driving seat of your car – before you fasten your seat belt, adjust the position of your seat so that you can sit upright with your back pressed flat against the seat upright, which should not be sloping, or if at all, only very slightly. At the same time, your feet must rest comfortably on the pedals, and your hands comfortably on the steering without slouching or leaning backward. Adjust rear and side mirrors, so that you do not have to twist your body when reversing.

Always avoid twisting your body when turning. Turn your entire body in one piece, as if you were spinning on your own axis.

At the wash-basin – do not stoop over a low wash basin. Stand with your feet well forward under the edge of the basin with one foot slightly ahead of the other. If you have to bend, bend at the knees and lower yourself while at the same time bending slightly at the hips. Your back should be straight without being stiff.

In the kitchen or pantry – often kitchen or pantry table tops have cupboards below them. This entails stooping when cutting food items. There should be a special cutting area, where there is no cupboard below it, so that you can get your feet well under the table and bend forwards at the hips with the back straight. Alternatively sit comfortably on a stool and get on with your work.

When ironing – if you have seen an experienced carpenter planing wood at his work table you will note that the table is of such a height that he can stand comfortably and do his job with only a slight bend at the hips. In similar fashion adjust your ironing board so that you can work without stopping.

Opening heavy-bottom drawers – Never stoop and pull on the drawer! Stand close to the chest of drawers, bend your knees with the hips slightly bent and your back straight and drop down, so that you can place your hands on the handles with the elbows bent to a right angle. You can now pull, taking all the weight on the legs, without putting any stress on the back.

It is essential that when you lift or push or pull on a weight, the stress is taken by the legs and not by the low back, hence the necessity to let your body drop to the level of the weight.

Lifting heavy weights like flower pots etc.– place your feet on either side of the pot. Go down to the pot, knees bent, hips slightly bent and back straight. Grip the pot firmly. Now lift by pushing down on the floor, straightening your knees, taking the weight and thrust on your legs and saving your back Ensure that the weight is as close as possible to the body.

Avoid holding the heavy object away from the body because it subjects the low-back to a very strong levering force. It helps if when carrying out these activities, you tighten your abdominal muscles, and tuck the tummy in. Watch a professional wrestler and you will understand what I mean.

Sweeping under a bed – again, go well down by bending your knees and hips so you can see where your broom is going!

Next issue: Some simple exercises

 Part 2
Helpful exercises, back pain or not
By Dr. Mark Amerasinghe
Some useful exercises
a) Sit on the 'correct' type of chair. Tuck your tummy in by tightening the abdominal muscles. At the same time press the hollow of your back to flatten it out against the chair back. Count to 5. Relax and repeat. Do not hold your breath while doing this exercise.
You should be able to carry on a conversation comfortably while doing it. Pushing down with your arms on the sides of the seat or with your elbows on the arm rest helps greatly. You may have some difficulty in doing this exercise at first, but it is worth trying. It pays dividends.

Bending the wrong way to pick up something off the floor.

After completing the exercise, when getting up from the chair (in the manner described earlier), try to keep the abdominal muscles contracted and the back flat and see if you can maintain this position in the standing and walking position.Initially repeat 10 to 15 times then gradually increase the number till you come to 20 or 30. You can do this exercise any time of the day (avoid the two hours after a meal) as no one will notice that you are exercising.
You will automatically have a better posture and you will walk and talk tall!
b) Once you have mastered this exercise on the chair, you can do the same in bed, before you get out of bed. You need a firm mattress or you need to have a plank under the mattress.
Lie on you back, bend you legs up at the knees and hips, keeping your feet on the bed. Keep your hand on your abdomen, so you can feel the muscles contracting. Tighten. Count to 5. Relax. Repeat at first, 20 to 30 times. IF YOU HAVE A CARDIAC PROBLEM GET YOUR CARDIOLOGISTS APPROVAL PARTICULARLY IN REGARD TO NUMBER OF REPEATS PERFORMED!!!!
c) Assume the same posture as in b), Lift your head up slowly while your hands are on the abdominal muscles. Usually with the head lift alone, the muscles tighten. If not just raise the shoulders very slightly off the bed. Count to 5 then relax. Before you raise the head, take a deep breath and as you raise the head let the breath out slowly. When getting back to the starting position, breathe in again. Repeat initially 10 times and gradually work up to 20.
These exercises can be done even when you are having back pain, provided the pain is not unbearable, and they help to relieve the pain.
Many a patient has testified to the efficacy of these exercises, provided they are done regularly, back pain or not. Do not let up because you are free of pain.
You do not have to sleep on a plank, but your mattress must not sag. So either it must be firm or have a plank underneath it.
During an acute attack of pain, sleep on a side with your legs tucked up (roughly in the foetal position) so that the back is flat or slightly rounded. Hug a pillow and have another pillow between your tucked-up knees. The idea is that your body is not even slightly twisted. Furthermore, when your legs are well tucked up the hollow of the back is flattened out. When you turn roll yourself like a log in one piece, using the legs for leverage.
When getting out of bed, get close to the edge of the bed, turn on your side with legs tucked up, push yourself up while slipping your legs out of bed. Then push yourself up and out of bed as you did when seated.
As has been pointed out less than 5% of people with backache have a prolapsed disc and less than 10% of people with a prolapsed disc need surgery.
In summary
Most backaches are posturally induced.
At all times avoid twisting your body.
Bend by bending the knees and hips without stooping. Remember this when  picking up even a slip of paper from the floor.
When pulling, pushing or lifting get the push, pull or lift from your legs, with your back straight.
Sit with a straight back on a straight-back chair or on the driving seat.
Keep your abdominal muscles strong.

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