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July 19, 2009
Over the years, I have worked with literally thousands of people who suffer from mechanical lower back pain. During that time, I have identified several self management tips that are worth knowing. These tips fall into the category of “management of biomechanics” during activities of daily living.
First of all, most people who suffer lower back pain experience the pain episodically. Each episode is worse, last longer and over time, starts to come on more frequently. This is typical, and is the main reason why management of lower back pain is worthwhile.
My tips are these:
- The pain is worse in the morning, and there is more risk in the morning. It is important then, to take care of the back first thing out of bed. This is true because during the night, the disc imbibes water creating increased intradiscal pressure in the disc before you get out of bed. You are indeed taller when you wake up than when you go to bed! So the first tip is to be cautious in the morning. I have advised people who have significant morning pain to actually get up in the middle of the night and walk around for several minutes as a way to mitigate the morning pain.
- Walking is great medicine. The literature points out that maintaining your activity is of no harm, and I believe necessary to overcome episodic back pain. Sub maximal exercise gets your blood circulating, relaxes your muscles and generally promotes good health. The weight bearing also compresses the disc and squeezes some of the water out, meaning less pressure on the nerves. So a good walk every day is helpful.
- Biomechanics is key. Be thoughtful about what you do. Face the things you do, keep lifting to a minimum, but when you do lift, keep the object as close to your center of gravity (around your belly button) as possible.
- Avoid prolonged sitting. And when you do sit, a firm chair with back support and arm rests is ideal. Try to use lumbar support when you sit. For instance, when getting on an airplane, put one of those little pillows behind your back.
- Use prolonged ice daily. I mean ice plus water in a plastic bag right on the skin for at least 30 minutes. The cold penetrates at about one cm every 10 minutes. It takes a half hour to numb the muscles and dull the pain. Be careful not to use gel ice packs because they tend to be too cold (if your freezer is below freezing) and not stay cold for long enough.
- Finally, get fit. Fit people have a much lower incidence of lower back pain than the population at large. This is more of a long term strategy, but if you are stronger, your muscles do a lot to support you. Along with this of course goes flexibility and core stability. Develop your core and don’t forget your back side when you do so. Core exercises include hamstring exercises, and back muscle exercises as well.
Back pain tends to be episodic, the episodes tend to be more frequent over time, they tend to last longer each time and also to be more severe each time. Reversing these trends is the goal of managing your back pain. Follow my advice and you will be able to do so!
Good luck
Neil
Filed under: abdominal exercise, acute back pain, acute LBP, acute pain, aerobic exercise, back pain, buttock pain, Chronic injuries, core stability, disc herniation, facet joint pain, health status, injury prevention, LBP, low back pain, lower back pain, lower cross syndrome, mechanical traction, nerve root compression, pain in the butt, Physical therapy, physical therapy for back pain, posture, return to function, segmental instability, SI joint, SI joint belt, SI joint Sacro-iliac joint, SI joint stabilization, SIJ pain, SIJD, Uncategorized, weak abdominals | by Neil Chasan, PT, MMT @ 11:23 am | |
Comments (0)
May 30, 2009
This was an interesting case that I thought worth mentioning.
In men, the SI joint rarely is the cause of LBP in my experience. In women of course, with a wider pelvis, and the hormone Relaxin softening the ligaments during the first and third trimester, we often see SIJ related pain especially post partum.
I recently saw a 60 year old male patient who had a three month history of pain that was so severe he was unable to tie his shoes or put on his socks. The pain was primarily in his right butt cheek and also in his upper thigh. His physician had ruled out his lumbar spine as the source of his pain. He eventually came to see me when he concluded that he was not getting any better with the passage of time.
His pain occurred when he bent over with his legs wide apart to lift a heavy object. The pain remained essentially unchanged during the past three months in spite of meds and rest.
My suspicion of the SIJ was confirmed by physical exam, and confirmed again when I reduced the subluxed joint.
So the lesson is this:
- Sudden onset unilateral pain in the butt that doesn’t seem to get better with time suggests Sacro Iliac Joint pain
- Pain that comes on with an incident, traumatic, lifting or otherwise suggests SIJ pain.
- Pain that meds and rest does not resolve that interferes with weight bearing or hip flexion suggests SIJ pain
Not all back pain is back pain. Not all buttock pain is SIJ pain.
The combination of the history (which raises suspicions) and the physical exam which (confirms or refutes them) is the way to make the diagnosis. BUT, if you have unilateral pain in one butt cheek, AND there is an incident that preceded the pain, THEN you might have SIJ pain even if you are not a post partum female.
The dysfunction is easier to treat in men than women, but it can be treated in women successfully along with a stabilizing belt following the reduction of the subluxation that I wrote about earlier.
December 4, 2008
The Sacro Iliac joint is complex for sure. Besides having to axis of motion and a weird shaped joint surface, there are two of them, all the muscles that cross it have more than one joint that they control, the symmetry or lack of symmetry between the joints add a degree of complexity as well, and the entire weight of the upper body is transfered through the SI joints to the lower extremities.
This is an x-ray of the SI joints looking down on the middle of the joints from the top:
I will say this: We see many more problems with women than men with respect to the SI joint. The reasons for this are first, the wide pelvis and the shallower SI joint angles, second, the impact of hormones on ligament laxity, and third, the consequence of pregnancy (change in weight bearing loads and angles combined with ligament laxity). We usually see SI joint problems in people who were not recently pregnant after trauma of some sort. For example, runners who land in a hole or shallow spot unexpectedly, or people involved in a sudden breaking event or head on impact in a car for example.  My point is that absent pregnancy it is rare to see a true SI joint instability. On the other hand, we do see restrictions of SI joint mobility that do have consequences at the hips and lower back for example.
How do you know if your SI joint is irritated? Well, if there is a true hypermobile SI joint that is symptomatic, you will most likely have unilateral pain in your buttock. In the event that the joints are simply hypomobile, then it is harder to determine on your own, and a good evaluation will reveal the restriction. Unfortunately, the symptoms that the irritated SI joint usually cause are also symptoms of other typical issues like lower back pain of discogenic origin, and a good physical evaluation is key to sorting out your symptoms.
The real challenge in treating the SI joint is not so much the hypomobile structure, because it is relatively easy to get a stuck joint moving again, but rather, the challenge is to stabilize the hypermobile joint. The reason for this, I alluded to earlier, and that is that every muscle that crosses the SI joint also crosses or controls another joint. For example, the Piriformis muscle is the major muscle that crosses the joint close to the joint line. But while the Piriformis muscle inserts on the inside of the Sacrum, it also inserts on the femur crossing the hip once it exits the pelvis crossing the SI joint.
 You can see how intimately the Piriformis muscle relates to both the SI joint and the hip and the adjacent hip muscles as well as the Sciatic Nerve.
So what do you need to do if you think you have an SI joint problem? First of all, use ice over the gluteal muscles. It seems to make a big difference. Second, get a good evaluation because the maneuvers that you need to make to figure this out need someone specialized to test and observe. Third, (and this depends on the evaluation) you will either need stabilizing exercises or mobilizing exercises. Finally, footwear might play a roll (Excessive pronation or supination will lead to stress across the SI Joint.) If you need stabilization though, an SI joint belt might be of service. This is often hit or miss though, but definitely worth a try.
My best advice is to get a good mechanical evaluation by a physiatrist, a physical therapist or a chiropractor, because that will determine the specific treatment strategy you need.
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