I have had many years experience of trying to work out how to cope with back pain, both as a sufferer myself and as a Pilates instructor and so thought I’d share some of what I’ve learnt with you below. What I think is key is self-education. That is generally missing from any thorough diagnosis and without awareness and self help, it is very difficult to work out how to improve. We are all generally ignorant about our own bodies and how they work and becoming aware of how you stand, how to engage key muscles and how to build on that is the most important focus for us all. To start with you will be consciously controlling the muscles but the ultimate aim is that hopefully over time you will end up with an unconscious, more supportive control of your muscles.
Let me just say in advance, that the only guarantee I have learnt regarding advice on your back pain is that it is almost impossible to get a correct diagnosis on what to do about it because your GP, your surgeon, your physiotherapist or your fitness instructor will all say different things. So the key is to take the issue into your own hands and work out how best to deal with your own type of pain. When a specialist suggested I take up Pilates, I told him I was already a Pilates instructor so he then said, “oh, well maybe you’re doing too much Pilates then.” It is a basic fact that the popularity of back operations, or in other words, the number of those who have had them done, tends to be directly related to the number of spine surgeons who live in the city.
Unless you’ve had a bad accident or played a lot of contact sport, most back pain is caused by bad posture or lack of movement, although sadly that is not the case with me (I blame my mother and my Grandfather). But assuming there is no serious spinal pathology like a tumour or violent trauma or the Cauda Equina Syndrome (CES) where you have a sudden onset of lack of control of bladder and bowels and need an emergency operation, then there are a lot of other options for you to consider prior to committing to an operation.
There is surprisingly little evidence-based practice and it is the worst area of orthopaedics to get a correct diagnosis because spines are so complicated and if you do a little delving, or talk to specialists, you will find that lots of what has been done to try and remedy back pain doesn’t really work.
My mother is a case in point. She now has 17 2″ Titanium screws in her back after two operations and her back pain is worse than ever. Additionally she now suffers from nerve pain in her neck and her arms because once you surgically stabilise one area of the spine, it inevitably destabilises another area. Because of her and despite the advice I have been given about having an operation, I am planning to do all that I can to put it off for as long as possible.
It is now common knowledge that anti-inflammatory drugs such as ibuprofen have little more benefit than a placebo when it comes to treating back pain, they might be a short term solution but can cause long term damage to your body.
Pilates has recently been recognised as an exercise that can help support the pelvis and spine in general and therefore can ease back pain. It is a popular exercise – “yoga for the godless” and a good place to start in beginning to strengthen your core muscles. One orthopaedic surgeon told me to “use your body and don’t be afraid to do so. You might have pain but you won’t hurt yourself.”
WHAT CAN YOU DO TO HELP WITH BACK PAIN
Firstly, you need to ask yourself the following questions:-
When does the pain occur?
How is your posture?
Do you need a new mattress?
Do you need supports in your shoes?
Are you overweight?
How strong are your abdominal, gluts (bum) and hamstrings muscles?
How sedentary is your job?
How much do you move around?
How much exercise do you do?
Is it the correct sort of exercise?
How much driving do you do?
What happens when you walk? Experiment with different styles. What happens if you tilt the pelvis under a little more and raise up your ribcage to ease the pressure? Does this make a difference? What happens if you squeeze your bum a little from the outside? Does this support more? What about if you are lighter on your feet and bounce more – this engages the calf muscle and hamstrings more so takes away some pressure from the back. What about when you engage your pelvic floor muscles?
Depending on the answers, have a think about the practical things you can change like a new mattress, different shoes, a back support in the car, a review of your work space, or physical changes; more movement, different exercises to develop stronger abdominals and muscle support in general.
GET A DIAGNOSIS ON YOUR BACK PAIN
Get your pain checked out. See a specialist, either an orthopaedic or neuro-surgeon – not really any difference – they are both spine surgeons. The ultimate aim is to stabilise the back, but be aware that a surgeon’s job is to operate, they are not going to give you a holistic viewpoint. Below are some of the things I was told by a leading surgeon that are worth looking into:-
An MRI scan is definitely worth doing, but bear in mind that anyone over the age of 20 is going to have an abnormal scan so it might not necessarily show the cause, unless you have a genetic condition or something specific. Progressive motor loss needs to be investigated – what is going on? Is the disc compressing the nerve?
However, don’t bother with an X-ray as it’s just radiation without information and mostly pointless.
CONSIDER SOME THE OPTIONS
There are many things to try that are invasive, rather than exercise based and below are some of the options that might be suggested to you:-
Injections – no evidence that it works, especially long term. I tried them. Made no difference, but they do provide temporary relief for some people.
Epidural Steroid injections:- not really for back pain and they won’t cure you and it can cause loss of feeling in legs. It can work for radicular pain which is pain caused by compression, inflammation and/or injury to a spinal nerve root arising from common conditions including herniated disc, foraminal stenosis and peridural fibrosis. They can also help you to commit to rehab as it does alleviate pain enough to do that.
Facet joint injections similar to the epidural information above.
Radio frequency nerve ablation
Use of electricity – good for elite sports people. Not a cure. Nature is the only cure as facet joint arthritis can often go away as the back gets stiffer in older people.
Lumbar discectomy: This should only be done if you have a foot drop or you are in agony or have Cauda Equina Syndrome and has to be done almost immediately. Otherwise better to wait six months trialling other things first. It tends to work well with sciatic pain, but there are always risks so the Orthopaedic surgeon I spoke to only operates on 4% of sciatic patients and after 10 years there didn’t appear to be much difference between those who had surgery and those who didn’t.
Endoscopic lumbar surgery: Recurrence rate of pain is 7-9%. Re-operation around 3-5% which is not nothing!
Lumbar decompression – lumbar spinal stenosis is very slow and reduces over years. Loss of function becomes obvious as you become more hunched over. Generally no neurological symptoms – no motor or sensory loss.
Laminectomy – very good for leg pain relief, but doesn’t help back pain and fluid collection is common and because it can cause gross instability a fusion operation might be required to stabilise the back.
Using screws to stabilise the back restricts movement of discs but is better than a total fusion because it can be reversed so it’s good for young people.
Prosthetic disc replacement – good idea in theory but the quote I have had from a surgeon is “this will 100% fail unless the patient dies first”. You are expected to move two dimentionally rather than three dimensionally so causes lots of other complications with movement.
Kyphoplasty – a medical spinal procedures in which bone cement is injected through a small hole in the skin (percutaneously) into a fractured vertebrae with the goal of relieving back pain caused by vertebral compression fractures.
A spinal fusion is the last resort and should only be done if everything else has been exhausted. You are destroying motion in an unpredictable way. Any time you interfere with movement there is a price to pay (same goes for bunion surgery!). The operation is long and complicated. My mother was under for 8 hours each time. This is followed by a painful 6 weeks, an uncomfortable 6 months and it will be 12 months before you know what the outcome is likely to be. 65% of people get a good outcome. 16% get not a great outcome and there are overall reported complications in 25-40% of cases. A fusion tends to be the gold standard. It’s meant to turn your unbearable pain into pain you can manage. Not guaranteed to be pain free. There are various ways the operation can be performed which I won’t go into as too technical. The issue here is weighing up the balance between your pain and your quality of life.
WHAT TO DO NEXT
Bear in mind it is how the results are interpreted that counts, so get second and third opinions if necessary. Take yourself off to various different specialists and try lots of things out to see what works and what doesn’t. Unless it’s an emergency, definitely try some additional exercise first in order to rehabilitate the spine as much as you can. If nothing else it will make recovery from surgery easier in the long run.
PILATES BASED EXERCISE
Fear of pain can make movement even more inhibited and the model of movement dysfunction is to try not to change posture – therefore you don’t get out of the cycle, so moving is generally a good thing, despite the pain.
Our spinal cord is protected by the vertebral column (also known as the spinal column or backbone). The human spinal column is made up of 33 bones – 7 vertebrae in the cervical region (neck), 12 in the thoracic region (middle), 5 in the lumbar region (lower back), 5 in the sacral region (pelvis) and 4 in the coccygeal region (tailbone). One of the main issues is a lack of control over the movement of the pelvis and lower back. Building muscle strength will help stabilise your back, so the rehabilitation of the spine is the best option initially for most people.
Aims of treatment
Reduce pain and inflammation
Restore range of movement
Rehabilitation of local and global muscles
Core stability – the spine is the most complex joint system in nature and designed to carry us on all fours, not on two legs, so the amount of work it has to do is really quite astonishing. We are inherently unstable anyway because 2/3’s of our body is above the pelvis so a loss of control of the spine affects the lumbar spine, pelvis and the extremities as well as upwards into neck.
The spine has lots of plasticity and adaptability to move. For functional stability, we need to focus on balance, posture and joint loading
Local muscles (stabilizers) are shallow
Global stabilisers – Gluteals, Spinalis, Obliques are deeper
Global mobilisers – rectus abdominals, Quadratus Lumborum, Latissimus Dorsi
The pelvic floor at the base, is also crucial, as is the diaphragm and abdominal muscle at the front, the parospinal and gluts – multifidus, they all co-activate muscle contracts. In order to engage your pelvic floor muscles you have to squeeze as if you are not only stopping the flow of wee, but a poo too. Sorry to be so basic, but that is simply the best description to use, try it whilst going to the loo if you’re not sure about where they are and then engage them during exercise and even about 30% when you are walking ideally.
Fascia is the largest connective tissue running through body that effects the different positioning of the body and also has a part to play so going to stretch classes can help a lot with this.
Beginner’s Pilates classes will help you begin to activate the muscles around the spine e.g. performing a bridge in a neutral spine and learning to use the pelvic floor muscles can help to start with.
Then you can move on to using hollowing techniques to introduce more strength – balancing, superman, bridge, side positioning etc.
Ideally you should try doing the classes three times a week at least, to integrate local and global muscles, using swiss balls, doing squats, lunges, slowly working the inner and outer muscles.
You could then move on to functional exercises involving sudden movements, jumping, landing, as well as concentric and eccentric training.
Let me know if this helps or if you’d like some more details on the sort of Pilates exercises you could try. I have many notes to share!