Experts Push Low-Tech Care for Back Pain

Washington -- In a major departure from traditional practice, federal health officials [Agency for Health Care Policy and Research] said Thursday that the expensive tests and therapies typically used to diagnose and treat lower back pain are largely useless.Instead they recommended over-the-counter pain medications, chiropractic and low-stress exercise, such as swimming or walking.

Roughly 85% of the general population experiences back pain at some point in their lives. Swimmer's are not necessarily part of the general population, as we spend part of the time in water. However, some swimmers injure their backs while doing dry land activities, and occasionally particular swimming related activities will lead to back pain. Anyone who has endured serious back pain, has most likely heard all their friend's and neighbor's back pain stories -- what worked for them and what didn't. The low back is mechanically one of the most complex areas of the human body. So, one person's back pain may be due to different structures being injured than another person's. The treatment for each type of back pain should be unique.

The eleven bones of the low back area consist of the lumbar spine (which are the last five vertebrae, or moveable segments, of the spine), the sacrum and tailbone (the boney area between the buttocks), the pelvis and, to a certain extent, the hips (femurs). Joints are surfaces where bone meets bone. Without going into excruciating detail, there are approximately 20 joints included in the low back area. Each joint is surrounded by ligaments. Ligaments act similarly to tape by holding the joints together, allowing movement in some directions while restricting it in others. Muscles not only move the bones, and consequently the trunk, but they also stabilize the trunk when the extremities are moving. The lower back area has large muscles extending more or less from the sacrum all the way up to the arms (i.e. latissimus dorsi), as well as many smaller muscles which only span one or two joints. Between the vertebral bodies are discs, composed of fibrocartilage and a gelatinous substance. They act as shock absorbers. The spinal canal runs inside the vertebrae and includes the spinal cord and spinal nerve roots. The nerve roots exit in-between the vertebrae and travel to all different parts of the body. The nerves which exit between the lumbar vertebrae supply the buttocks, thighs, legs, feet, as well as organs such as the intestines.

With all these different structures to think about, it is not surprising that different theories have evolved on what predisposes one to lower back pain. Four schools of thought as far as rehabilitative exercises are concerned: McKenzie -- The Lordosis Theory Low back pain is due to a flattening of the normal lumbar curve (also known as a lordosis), thereby stressing the pain sensitive muscle and articular components of the back. Treatment is directed toward extension (backwards leaning, Cobra position in yoga) of the low back, thus accentuating the lordosis. Butterfly and breaststroke typically require a lot of lower back extension and MacKenzie exercises can help increase that extension. Williams -- There is a lower incidence of back pain in agrarian cultures in which people regularly assume a "squat" position, thus flattening the lumbar spine. Low back flexion exerxcises and treatment maneuvers were developed based on this observation. The forward flip turn increases lumbar flexion. Muscle imbalances -- Tight muscles, such as hip flexors (psoas, rectus femoris) inhibit weaker muscles, such as abdominal muscles. The treatment is first directed toward stretching the tight muscles and then strengthening the weak muscles. Although certain patterns exist, each patient must be assessed individually.

If your hip extensors (gluteus max, hamstrings) are weak, in order to achieve hip extension during the flutter kick, you will tend to use your lumbar erector spinae muscles (low back muscles). Needless to say, you will probably not be the swiftest flutter kicker, and you'll probably experience low back pain after long kick sets.

Proprioceptive deficits -- Proprioception is the ability of the brain/nervous system to asses the position of a joint in space. Good proprioception is important for balance. While most exercises are floor exercises (on a stable surface), most people injure themselves when their body is off balance (i.e. pulling clothes out of the dryer). Proprioceptive exercises train the body to maintain stability and balance in different situations. These exercises are often done with the Swiss ball and/or rockerboards and wobbleboards. They are expecially important for swimmers, as swimming takes place in a fluid environment offering minimal support.

In my opinion, a good practitioner will choose exercises from all the schools of thought as are appropriate for the individual patient. In other words, the best exercise program must be individually taylored to the patient based on his/her diagnosis and predisposing factors. Rarely is one exercise the solution for a back problem. It is usually a combination of exercises.

A person experiencing low back pain may have damaged any of the structures mentioned above. Some of the most common problems are: Joint locking/subluxation: If the joints are not moving symmetrically in all possible directions, an imbalance is created. The locking itself may be painful or may lead to compensations, such as tight muscles, improper body mechanics, irritation of the structures adjacent to the locking. The lumbar facet joints and the sacroiliac joints often exhibit this problem. A slight joint dislocation or malposition of bones is often called a subluxation (although chiropractors will also often include joint locking under the term subluxation as well). This is commonly seen in the sacroiliac joints. Joint locking or subluxations predispose one to many of the following problems. Trea tment: chiropractic adjustments. Assess for predisposing factors, such as muscle imbalances.

Muscle strain: tear in the muscle fibers. Usually a mechanical cause, such as lifting a couch awkwardly, or spending a long period of time doing an unaccustomed activity, such as gardening. Muscle strain may also result from poorly functioning joints (see above). Treatment: Initially ice, then alternate ice and heat, rest the muscle, physical therapy modalities (such as ultrasound, interferential current), assess for predisposing factors such as joint locking, muscle imbalances.

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