BACKACHE RELIEF NOW! Version 5.6 (c) 1992 A shareware package from Jim Hood & Seattle Scientific Photography POB 1506, Mercer Island, WA 98040 (206) 236-0470 CIS: 72020,2176 Suggested BBS name for this tutorial: BKACHE56.ZIP ---------------------------------------------------------------- How to install: this software must first be installed prior to use. Type the command INSTALL . You may install to or from a hard drive or floppy drive. How to run: after installation, start the program with the command GO DESCRIPTION With over 7 million backache sufferers and 2 million added each year, this is a thorough and medically conservative tutorial written for the average layman. Topics include: spinal anatomy, backaches and computer operators, chronic backache, arthritis, chiropractic manipulation, the "slipped" disc, aging and back pain, tumors, infectious diseases, posture and backaches, medications, new medical technology, exercises, the orthopedic examination, surgery, pregnancy and backache, little-known therapies, the anthropology of backaches and more! Colorful popdown menus, help screens and high speed search features guide users through a variety of tutorials which can be printed or read on screen. Registered users ($25.00) receive a printed back care study and exercise guide plus two software disks. This software requires CGA, EGA, VGA graphics. FILES ON DISK Prior to installation: README General information, this file INSTALL COM Installation system file FILE_ID DIZ Short program description for BBS use LHATXT EXE Documentation on LHA archiving system ORDER EXE Automated registration program PART1 EXE Tutorial files part one PART2 EXE Tutorial files part two PART3 EXE Menu and runtime files PART4 EXE Configuration data for HD installation PART5 EXE Configuration data for floppy installation ORDER FRM Registraton order form, standard ASCII file After installation: README General information PIC 1 Runtime graphics configuration GO BAT Main startup batch file, runs program BOOK CFG Config file for HD use BOOK1 CFG Config file for floppy use BOOK2 CFG Config file for floppy use BACKACHE EXE Primary menu MSHOW EXE Graphics runtime ORDER EXE Automated order system for registration ORDER FRM Registration order form 001 PCX Graphics splash screen AGING TXT Aging tutorial ANAT1 TXT Anatomy tutorial, part one ANAT2 TXT Anatomy tutorial, part two ARTH TXT Backaches and arthritis AUTHOR TXT About the author of program CAUSE TXT Causes of backache CURVE TXT Curvature and shape of spine DISC TXT The slipped disc EXAM TXT Physician's exam EXER1 TXT Basic back exercises EXER2 TXT More back exercises PERSP TXT General introduction PREG TXT Pregnancy and backaches REMED TXT Home remedies START TXT How to use menu, general intro TRAUMA TXT Trauma and back pain TREAT TXT Medical treatments If you are new to computers you may not have heard the term SHAREWARE. Basically this means an author or group has prepared a software program which you are free to copy and share with others, but the author of this software requests a REGISTRATION FEE. The idea is that if the program is useful you evaluate it for a limited period (usually 30 days) and then become a legally registered user of the program by paying the registration fee. If you do not wish to register, you are expected to cease using the program. Shareware is an honor system. Are you registered if you "found" this tutorial already installed on your computer or purchased it from a computer club or shareware disk vendor or other retailer? Probably not. ONLY registered owners receive a printed registration with unique registration number and four special diskettes. You can ONLY become a registered user by mail through the program's author. This package is shareware which means try before you buy. It is acceptable to copy and share it with friends - but only registered PAYING users receive the bonus disks, registration certificate and latest update. The sole owner of this software package is Seattle Scientific Photography and Jim Hood who assume no liability, intended or otherwise, for the use or misuse of this package or the information or software code contained within. No warranties are offered, either expressed or implied. Your rights in this respect may vary from state to state. You are granted a limited license to copy and use this shareware software for a 30 day evaluation period pending your possible submission of a registration fee which brings additional benefits and a legal registration license allowing continued software use. ---------- LET'S BEGIN... ---------------------------------------------------------------- Backache Relief Now is a tutorial system which provides dozens of practical reference articles for specific back pain relief. In a way Backache Relief Now is simply a book on a computer disk. But this tutorial offers more speed, flexibility and FUN than any printed book. A LARGE amount of practical reference material has been packed within this program. The best thing to do is take your time since you can always come back to the tutorial for a paper printout or search for a tip using the powerful software utility tools built into this software program. If you are at the main menu, use the cursor direction keys (arrow up, down, right or left) to move to any menu item then press the return or enter key to open a tutorial section. Once you are reading a tutorial use the PAGE UP (Pg Up) and PAGE DOWN (Pg Dn) keys to move up and down through a tutorial - just like turning pages in a book. Within any tutorial, the F1 help key tells how you can control colors, turn sound on/off, search through the tutorial for a title or phrase, print entire sections on your printer and more. In fact, try pressing the F1 key right NOW and glance at the help screen for a preview of the special functions you can activate from within any of the tutorials. While reading a tutorial, a reminder line appears at the BOTTOM of the screen to provide helpful hints. When you reach the END of a tutorial, press the escape key to return to the main menu. You may also press escape at any time to return to the main menu. ---------------------------------------------------------------- HOW TO RECEIVE YOUR PRINTED BACK PAIN GUIDE AND BONUS DISKS ---------------------------------------------------------------- What does your $25.00 registration purchase, payable to the author of this software program, bring to you by prompt postal delivery? 1) A 22 page printed guide to back pain which includes detailed anatomy illustrations and photographs of additional exercises and therapy suggestions to enhance this basic tutorial. We do not have space in this short tutorial to include pictures of the dozens of additional treatment strategies which will help you conquer your backaches. Refer to this printed guide as you plan your personal recovery from back pain! The guide is the intended manual which accompanies this disk. 2) An UPDATED copy of this software in case you are using an older version. 3) An additional bonus software disk. TO REGISTER, a $25.00 fee is requested and appreciated! See the registration option elsewhere on the main menu, or execute the command ORDER which automatically processes the order form which is a file named ORDER.FRM. You can also activate the automated order program from the main menu. If you are new to computers you may not have heard the term SHAREWARE. Shareware is an honor system. Basically this means an author or group has prepared a software program which you are free to try, copy, and share with others, but the author of this software requests a REGISTRATION FEE. The idea is that if the program is useful you evaluate it for a limited period (usually 30 days) and then become a paid, legally registered user. If you do not wish to register, you are expected to cease using the program. Are you registered if you "found" this tutorial already installed on your computer or purchased it from a computer club or shareware disk vendor or other retailer? Probably not. ONLY registered owners receive a unique registration number, illustrated guide and bonus disk. This tutorial is merely a starting point! For further information on back care and back pain, be sure to register this software ($25.00) which brings by prompt postal delivery a printed, illustrated guide to back pain written by a physician plus two software disks. From the main menu select "Print Registration Form." Or from the DOS prompt type the command ORDER. Mail to Seattle Scientific Photography (Dept. BRN), PO Box 1506, Mercer Island, WA 98040. If you cannot print the order form, send $25.00 to the above address and a short letter requesting these materials. End of chapter. Press escape key now to return to main menu. ---------- BACKACHES AND BACK PAIN: A PERSPECTIVE ------------------------------------------------------------ The statistics are staggering. Each year more than 7,000,000 people in the United States report to their physicians suffering from backaches. More than 500,000 workers suffer on the job back injuries annually. And over 2,000,000 new backaches are added every year. If back pain was an infectious disease it would have been declared an epidemic years ago. Chronic backache is our most silent and painful epidemic. The cost of backaches in terms of lost time, wages and productivity run into billions of dollars annually. Some insurance companies report that reimbursements for back therapy and back surgery leads all other diseases in terms of total payments for medical care. On average, one out of four people gathered at random will report having a chronic, continuous backache within the last month. More than 30% will report having had a severe back strain or "sprain" within the last six months. And more than 20% of chronic back pain sufferers will request surgical intervention. Recently a large corporation held a "health fair" at its company headquarters. Presentations were offered on topics such as nutrition, exercise, pregnancy, aging, alcohol abuse, smoking and other health topics. Those who organized the health fair were stunned when employees overwhelmed a single presentation on back pain which had to be repeated FIVE times in order to accommodate all who requested seating at that specific presentation. Something is seriously wrong when a majority of individuals report chronic nagging backaches. And what is more frightening is that if neglected, back pain can yield to more severe permanent structural changes in bone, muscle or tissue. But there is hope. Amazingly, the majority of backaches can be relieved with common sense therapies, exercises and a simple understanding of anatomy. You do NOT need to suffer back pain. Make no mistake. You have to USE the ideas within this tutorial. You have to DO the exercises and try the suggestions. And of course you should have your physician CHECK your back and spinal condition prior to proceeding if your back pain is severe or chronic. You cannot handle your back pain simply by reading this tutorial, although it is a start. You can make backaches vanish if you decide to follow a few common sense therapeutic behaviors. Why does this software program exist? Because I needed this information myself. As a computer programmer I spend long hours sitting in front of a keyboard. Inevitably back pain found me and I did the wrong thing: I ignored it. The agony became worse until I decided to do some research. In between writing other software programs I spent almost a year investigating the topic, talking to physicians and thinking about what I could do to prevent back pain. Naturally my stack of notes became the perfect candidate for a software tutorial program and an ideal "electronic reference" I could use from time to time if my back pain returned and I needed to look up a reminder, an exercise or a tip. It's a bit ironic that long hours in front of a computer caused my back pain, yet some simple research produced a software program which helped relieve the backache which the computer caused in the first place. Let's move on in our tutorial and begin with the basics of human back and spinal anatomy.... This tutorial is merely a starting point! For further information on back care and back pain, be sure to register this software ($25.00) which brings by prompt postal delivery a printed, illustrated guide to back pain written by a physician plus two software disks. From the main menu select "Print Registration Form." Or from the DOS prompt type the command ORDER. Mail to Seattle Scientific Photography (Dept. BRN), PO Box 1506, Mercer Island, WA 98040. If you cannot print the order form, send $25.00 to the above address and a short letter requesting these materials. End of chapter. ---------- BASIC ANATOMY PART ONE ------------------------------------------------------------ With over 140 muscles attached to the 24 vertebrae of the spine and supporting structures, the human back is a miracle of engineering. While the human brain may be more complex in design, the human back is more sophisticated in terms of mechanical engineering. Consider the mathematics... If you bend forward at the waist so you are at about a 65 degree angle from vertical, and assuming you weigh about 180 pounds, 450 pounds of muscle force is needed just to keep you from losing your balance and falling over. If you happen to carry a 50 pound weight in this position, the muscle force rises to 750 pounds. At the same time over 850 pounds of direct force will be exerted on the fifth lumbar vertebra. The fact that the spine can be flexible, rigid and twist under varying loads and circumstances is a tribute to evolution and engineering on a biological scale. Despite its impressive performance, the design of our back and spinal column is flawed. During our brief evolution from quadrupeds or four legged walkers into bipeds or two legged walkers nature did not completely finish the job. Quadrupeds such as cats, dogs and horses - and presumably four legged walking primates from which we evolved - use a spinal column which is more evenly supported by four legs which serve as support pillars. This conservative engineering system provides a stronger design much like a suspension bridge with the spine held horizontal and supported by four vertical pillars. When man evolved into a bipedal erect walking creature, this intrinsically sound design was lost and two of the support pillars, our arms, lifted up into the air. To compensate for this weaker design, the stomach, hip and back muscles act as delicate "guy wires" in much the same manner as you might tie a young tree upright with three or four ropes to keep it from toppling over in the wind. The fact that over 90% of disc and muscle related spinal injuries occur in the LOWER spinal area gives testimony to the imperfect design which our accelerated primate evolution delivered to of our spinal and muscular anatomy. In truth, the complicated nature of its design and its slowness to adapt to our relatively recent upright posture makes our backs more susceptible to injury and pain than most other body organs and structures. Your back hurts because its evolution is still catching up with the sudden adoption of an upright posture. Surprisingly, it was BOTH our brains and backs which played the most dramatic role in our evolution since walking erect freed our hands which, along with our developing brains, led to new skills such as tool making, agriculture and writing. Our brains have drawn praise during evolutionary change, but our backs have borne the brunt of a shortened and as yet incomplete evolution. Let's turn to specifics. A brief course on anatomy... The spine has three functions. 1) To support your body, anchor your ribs and connect the pelvis and head. 2) To protect and house the spinal cord whose nerves connect most major body organs to the brain. 3) To provide flexibility, balance and mobility. The spinal column or backbone, is a series of separate bones called vertebrae. Curiously, the vertebrae are not precisely the same size nor are they stacked exactly on top of each other. Rather, to balance with forces of weight and various organs, they are arranged in a precise S curve which is seen when the spine is viewed from the side. Each vertebrae, depending on its shape and the muscles and ligaments which attach to it rests at a slight angle. The spine can be divided into four regions, each of which is quite unique in form and function. 1) The neck region or cervical spine consisting of 7 vertebrae whose function is to support the head. These vertebrae permit the extraordinary range of motion for our heads, eyes and ears. 2) The middle back or thoracic region consisting of 12 vertebrae which are slightly less flexible since they provide attachments for the bones of the ribs. 3) The lumbar spine or lower back consisting of 5 large vertebrae which support the substantial mass of our body weight and which bear the brunt of many opposing forces. These vertebrae are broad and heavy which reflects this task. It is this region of the spine which suffers to most wear and tear from poor posture, sudden trauma and other injuries. It is also this region which displays pain most frequently when people visit the doctor for backaches. 4) The coccyx and sacrum region. The sacrum is a triangular, broad bone attached to the base of the spine which is formed from the fusion of 5 separate bones during early pregnancy and gestation of an infant. Finally, we arrive at the coccyx which is the lowest bone of the spinal column. It is a collection of small bones which are probably all that remains of our primitive vestigial primate tails. If you were to remove one vertebra from the spine you would see that it is a solid cylinder of bone with a hollow canal through the middle for the spinal cord. The hole through each vertebra is called the vertebral foramen. This hole is the primary conduit which houses and protects the spinal cord. Three crucial spurs or projections of bone extend from the back or side of each vertebra. One spur points straight back and is called the spinous process - if you feel your backbone with your fingers you can feel the point of each spinous process along the length of your back. The two other spurs point to the side and are called transverse processes. The single spinous process bends down at an angle and overlaps the vertebra below it. This overlapping tends to provide additional protection for the delicate spinal cord much like shingles on a roof. The two sideways-pointing transverse processes serve to act as anchor points for muscles. Between each vertebra is a tough capsule of ligament which encloses an elastic, jelly-like substance called the nucleus pulposis. To the average lay person this is the "disc" but in fact it is several structures. 1) the outer band of ligament. 2) the flexible gel within. 3) on top and bottom of this whole affair are a pair of tough cartilaginous plates which are the bearing surface upon which the vertebrae rest. Each specific region of the disc is designed for a unique function. A single disc is a composite of several types of tissue, each with a different composition and function. If the spine lacked these "shock absorbing" discs, the vertebra would rub directly against each other and soon destroy the whole structure as well as doing damage to the spinal cord. The clever construction of the discs absorbs shock and distributes spinal pressures evenly in all directions. In early life the disc spaces between vertebrae are wide. As we age, changes begin to take place and the disc gap narrows. The disc loses flexibility, drying out proceeds and scarring from wear and tear can begin. But this can also be a function of use as well as aging. A 70 year old man can have good discs if he has been active and careful while a 30 year old sedentary office worker can have poor discs. The discs expand and contract slightly during the day due to the effects of gravity and work. When you wake up in the morning you are slightly taller than at the end of the day. Astronauts also "gain height" in the weightlessness of space where the discs are freed from the bonds of gravity. The structures of the spine are not the complete bony anatomy of the back. Next we come to the pelvis which is a large bony structure on which all of the lower soft organs rest. This includes the large intestine, uterus, bladder and rectum. At the lower end of the spine the backbone rests on a junction of three bones: the sacrum, a broad triangular bone mentioned earlier, and the right and left and right illium bones. Thin, tough ligaments connect the illium bones to the sacrum. This ligament is known as the symphysis pubis and it is this junction of illium bones and sacrum that gives rise to the famous and sometimes painful "sacroiliac" joint. Moving to the front of the pelvis are the two large sockets or acetabula into which the joints of the upper leg or thigh bones fit. Other than the thin joint between the illium bones and the sacrum, the remainder of the pelvis is rigid and inflexible bone. In the female, the pelvis is wider and broader to allow for the demands of childbirth. The coccyx, our vestigial tail, is the lowest point of the spinal column and is a fused assembly of three or four small bones. The coccyx rarely causes much back pain, unless you have had occasion to slip on icy pavement or sit on a chair which was suddenly pulled out from under you. In a nutshell, this covers the bony structure of the back and spinal column. In the next chapter we move on to the soft tissues of the back: the muscles and ligaments which give this amazing bony foundation its strength, flexibility and tension. This tutorial is merely a starting point! For further information on back care and back pain, be sure to register this software ($25.00) which brings by prompt postal delivery a printed, illustrated guide to back pain written by a physician plus two software disks. From the main menu select "Print Registration Form." Or from the DOS prompt type the command ORDER. Mail to Seattle Scientific Photography (Dept. BRN), PO Box 1506, Mercer Island, WA 98040. If you cannot print the order form, send $25.00 to the above address and a short letter requesting these materials. End of chapter. ---------- BASIC ANATOMY PART TWO ------------------------------------------------------------ Everyone has head the term ligament. We think of football or basketball players who have "torn a ligament." Likewise most of us have head the term tendon. A ligament is a tough, dense strand of gristle-like tissue which attaches one bone to another while a tendon attaches muscle to bone. The two are thus different. Ligaments pass between two bones and have some flexibility so that motion can occur, but their elasticity is low. They can usually be stretched only a short length before a tear occurs. Once torn, a ligament does not normally heal itself and is repaired surgically. If left unrepaired, the unrestrained movement of the joint can cause additional pain, damage and loss of joint function. Many ligaments connect the spinal vertebrae, sacrum and pelvis into a single structure. 1) Interspinous ligaments connect the bony transverse spinous processes together and limit motion which can happen between two vertebrae. 2) Intertransverse ligaments pass between the transverse processes on each side of the vertebra. They are largest at the lower lumbar region of the spine and prevent you from bending too far from side to side. 3) The ligamentum flavum secures the rear section of vertebrae and forms the upper encasement of the spinal canal. It protects and covers the spinal cord and is a bit more elastic than most ligaments of the spine. 4) The annullus fibrosus connects each vertebra to its neighbor via a circular band. It contains the gel-like pulp of the disc. Curiously, its fibers are oriented in a radial ply orientation much like radial ply cords of an automobile tire. While it contains the pulp of the disc, its primary function is to hold the disc in alignment with its vertebral neighbors. 5) The anterior and posterior longitudinal ligaments which extend between the top and a bottom of the vertebrae in a longitudinal path. The muscles of our spine are for the most part under our conscious control unlike muscles of the internal organs such as the intestine or stomach. This is an important distinction since certain exercises which we can perform consciously can help alleviate back pain. It is also important to understand that the muscles within your back are only PART of the entire story. Other muscles outside the back region strongly affect the shape and structure of the back, notably the abdominal and buttock muscles. Four general groups of muscles support and affect your back. 1) The all important abdominal muscles which provide frontal support and keep internal organs such as the stomach in correct alignment. 2) Extensor muscles of the spine which hold the rearmost portion of the torso in an upright position 3) Lateral muscles which provide side to side support 4) Hip muscles which affect the spine by virtue of their attachment to the pelvis. Each of these groups of muscles works in concert with the other. One or several groups may contract while the others cooperatively relax. Just like the young tree with guy wires to hold it erect in the wind, several groups of muscles function together to add stability to a less than ideal spinal design. The abdominal muscles consist of 1) The rectus abdominus 2) internal oblique 3) external oblique 4) transverse abdominus. In addition to support for internal organs, when contracted and in proper tone, these muscles control bending movements of the spine and affect proper posture. Some backaches can be relieved by strengthening this group of muscles. The extensor muscles lie along the length of the spine. They are positioned in layered bands and have detailed names which are not necessary within this brief discussion. Some of the layers are long, usually those lying close to the skin. Other extensor muscle layers are short, and are those which are much deeper below the skin. The attachment points of this set of muscles is complex, with segments connecting to spine, pelvis, ribs and the head. They are most frequently used when you arch your back, pull a heavy weight or tense your spine rigidly. The lateral muscles, are layered into the side regions of the spine. Two major groups are apparent: 1) The quadratus lumborum and 2) The psoas major. The quadratus helps in bending and is used in dancing and gymnastics. The psoas is quite large and attaches to the top of the thigh after running along the side the spine. In addition, four muscle groups of the hips, although not directly connected to the spine, can intimately affect its shape and performance. These hip group muscles are 1) the hip flexors 2) hip abductors 3) hip adductors 4) hip extensors. Groups or combinations of these muscles can affect the tilt of the pelvis and the all important lumbar lordosis or curve of the lower back. The hip muscles dramatically control posture and exercise. Proper tension and tone of these muscle groups can affect back pain. The final stop on our anatomical tour of the back is the nervous system. Although the bones, muscles, ligaments and tendons form the mechanical structure of the back, it is the nerves which transmit sensations of pain. The tolerance for pain varies from individual to individual. A laborer or professional football player can endure one level of pain. An office worker or student perhaps a different level. The fact the back pain is often more nagging, virulent and unrelenting does not necessarily make it different - just more noticeable in our modern society. It seems most folks might be able to limp through the day with a toothache or muscle ache from playing weekend baseball. But back pain SEEMS different. It can lay you low and make you want to curl up in bed for days on end. The fact the few treatments SEEM to alleviate back pain makes it seems a special breed of pain. More unrelenting, debilitating and immune from the treatments of modern medicine. To understand backaches you need to glance at the anatomy of the nervous system. In man and most vertebrates the nerves are composed of thin fibers of tissue. The largest cluster of these fibers are obviously in the brain. The second largest concentration is in the spinal cord. Two separate structures distinguish the nervous system. 1) The autonomic nervous system and 2) the somatic nervous system. The autonomic portion of the system controls involuntary actions and senses. Functions such as vascular pressure, nutrition, heartbeat and digestion fall in this area. The somatic portion of the system governs voluntary actions and senses which we can consciously control like bending, looking, opening our mouths and so forth. At each level of the spinal chord are groups of nerves which receive impulses from transmission points like the skin and muscles. These are afferent nerves. Other groups of nerves transmit impulses from the brain and spinal cord back to the skin, muscle or site of origin. These are efferent nerves or motor nerves. Approximately 30 pairs of mixed spinal nerves emerge from openings in the vertebrae along the length of the spinal cord. The small holes which permit passage of nerve tissues through the vertebrae are known as foramens. The central spinal canal within each vertebra of course houses the spinal cord itself. Curiously the main spinal cord is housed in ONLY the upper two thirds of the spinal column. The spinal cord terminates and does not travel within the spinal canal lower than the first lumbar vertebra. In an infant the spinal cord does run the length of the bony spinal structure, but differential growth allows the spine to become longer while the growth of the spinal cord lags behind and thus occupies less than the full spinal column length in a mature individual. The nerves of the spinal cord continue their downward trip towards the legs and lower pelvis OUTSIDE the bony spinal structure once they have reached the level of the first lumbar vertebra. However the lumbar nerve roots do extend downward and emerge on the sides of the lower 5 vertebrae and sacrum. These lower lumbar nerve roots are extremely important in the production of pain from the classic "slipped disc" which we will discuss in a later chapter. From a practical standpoint what does this discussion of the nervous structure have to do with back pain? In simplest terms, this vast collection of nerves MONITORS a variety of locations which can cause pain: weak muscles, torn ligaments, torn discs, fractured bones and so forth. In some cases, efferent nerves can cause a specific muscle group to become overly tense and contract into painful spasm. This may be due to a torn disc, simple fatigue or poor posture. However this secondary muscle contraction in response to an initial pain can make a bad pain seem worse. We have looked at muscles, bones, tendons and nerves, but until this point we have not tied them together with a key word: SHAPE. Held together by the overlapping forces of various muscles, the spinal column assumes a precise S shape when viewed from the side. The reason why the spine is not normally straight is that varying forces and demands are present along its length. The S shape acts as an elegant "counterbalance" to these opposing forces. In fact, it has been calculated that the spine is 15 times stronger due to its natural S curvature than if it were straight! This S-shaped curve is formed from four separate curves. Two curves bend towards the front of the body and two curves arch toward the back. The rearward bends are produced by the precise wedging of the vertebrae and are called primary spinal curves while the forward arches are produced by the wedging of the intervertebral discs and are called secondary spinal curves. The primary curves probably arose as a mechanical strengthening design during our existence as four legged quadrupeds. The two primary curves are in a sense genetically "ancient." They have been with us and all four legged quadrupeds for a long time. The secondary curves of the spine arose much later during evolution and were necessary when our upright posture was assumed. In a sense, nature had to counteract the primary curves when we began to walk in an erect position. And the only way to do this was to add rearward secondary curves. Only man has these unique secondary curves which are located in the cervical region, near the top of the spine, and the troublesome and pain-prone lumbar region in the lower spine. As we age, the lumbar curve tends to deteriorate and actually begin to reverse its curvature. In women the lumbar curve is also more acute or pronounced. The curvature becomes still more pronounced with pregnancy to offset the protruding abdomen. This effect can also occur in people of either sex who are overweight. We will talk more about this in a later chapter, but it is sufficient to understand that these curves are unique to man, crucial to proper balance of the spinal structure and somewhat adjustable depending on age, weight and sex. This ends our brief anatomical tour of the back. Obviously both structure and function have been simplified, but understanding even this basic level of anatomy sets the stage for that which comes next: what are the causes of pain and ultimately how do you treat them? This tutorial is merely a starting point! For further information on back care and back pain, be sure to register this software ($25.00) which brings by prompt postal delivery a printed, illustrated guide to back pain written by a physician plus two software disks. From the main menu select "Print Registration Form." Or from the DOS prompt type the command ORDER. Mail to Seattle Scientific Photography (Dept. BRN), PO Box 1506, Mercer Island, WA 98040. If you cannot print the order form, send $25.00 to the above address and a short letter requesting these materials. End of chapter. ---------- THE CAUSES OF BACK PAIN ------------------------------------------------------------ In the previous anatomy lesson we described structure. In this section we take that knowledge and focus on CAUSE. With a structure as complex as the spine and its supporting muscles, tendons and nerves you might suspect that there could be hundreds of causes of backache and back pain. Amazingly, the list is small and concise. But consider that for each cause listed below there may be a different therapy to alleviate each specific back pain. Backache and back pains can arise from the following sources: Chronic or Severe Trauma such as prolonged sitting, twisting, strain or sudden mechanical injuries. Poor posture or curvature of the spine. Stress or Fatigue. A "slipped" or ruptured disc. Pregnancy. Birth or congenital defects. Arthritis. Systemic diseases. Hormonal imbalance and aging. Tumors or infections of the back or spine. Lets back up a bit. A list this short suggests that a backache is probably due to a single isolated problem. In reality back pain may derive from multiple causes. One cause can frequently lead to several others if treatment or correction is not taken. For example poor posture and muscle fatigue from sitting at a computer terminal for extended periods of time may give way to muscle fatigue which, over several years, may lead to muscle weakness and loss of tone. A sudden twist or impact might then rupture an intervertebral disc which would not have otherwise suffered damage if muscle tone were healthy. Another example. Stress and fatigue at work may set the stage for chronically tense back and abdominal muscles. Pain begins due to muscle fatigue or spasm. Poor posture develops to attempt to compensate for the pain. Over years, the poor posture can place extreme pressure on the intervertebral discs, causing them to gradually collapse in size. Lets examine each specific back pain cause... Posture and spinal curvature. Perhaps the most common cause of back pain is poor posture which causes incorrect spinal curvature when standing, sitting or moving about. You will recall in our previous anatomy lesson that the spine has four curves. Two primary curves which arch to the rear and are common to all four legged animals. The two forward bending curves are unique to man and are found at the level of the neck, the cervical curve, and the level of the lower lumbar vertebrae, the critical lumbar curve. Since the primary curves are a result of bony vertebral shape, they are relatively stable and rarely cause problems. The secondary curves are due to the positions and shapes of the flexible and more delicate intervertebral discs and thus can change with time, injury or disease. Poor posture can dramatically increase or decrease pressures on the discs. If poor posture is continued over many years, unusual stresses are placed on the supporting muscles, tendons and ligaments. Chronic or severe Trauma. Sudden trauma causes a lot of lost time on the job. Any sudden injury such as a fall, sudden twist, or blow to the back falls into this category. Chronic trauma is more subtle. One example could be years of poor posture at a desk or job site. Poor sleeping posture or an old mattress could would be another example. Driving a car and maintaining poor posture also produces chronic trauma. At a certain point in time the supporting structure of your back cannot stand the continued strain and pain occurs. In chronic trauma, the more severe the pain, the more severe the probable underlying injury. Arthritis. Arthritis in the classic sense simply means an inflammation of a joint. Three types of arthritis can attack the bones and joints of the back. 1) Rheumatoid arthritis involves the delicate lining or synovium of a joint which begins to grow and destroy the flexible cartilage. In its most severe form, rheumatoid arthritis leads to the destruction of the joint cartilage and the gradual fusing of the vertebrae together. 2) Osteoarthritis is by far the most common arthritic disease. Simplifying the process a bit, this form of arthritis is simply the wear and tear process of old age. The delicate surfaces and tissue of the intervertebral joint slowly wear down and become stiff. 3) Gouty arthritis can be traced to a chemical metabolism problem which allows excessive uric acid to circulate in the blood stream. Crystals of uric acid then collect in specific joints such as the back or the classic "gouty big toe" and extreme pain occurs. Gouty arthritis is rare but has been reported in medical literature. Ruptured or "slipped" disc. The first question most folks consider when severe pain visits is "do I have a slipped disc?" In fact this condition is uncommon as a source of back pain. In addition this condition is neither "a slipping" of a disc, nor is the structure even a disc at all. In reality it is a joint (not a disc) which has ruptured to some degree. As we saw in our previous anatomy lesson the "disc" is composed of a complex layer of tissues and is not at all shaped like a cylinder or disc. Intervertebral disc joint problems can visit anyone of any age, but are certainly not the most common cause of back problems. However, disc injuries are certainly the source of severe pain unlike that caused by bad posture or muscle stress. Don't jump to the conclusion that you have a slipped disc at the first sign of pain. Chances are that it is probably not the most immediate cause. However it is important to understand that chronic trauma, fatigue and poor posture can eventually lead to an intervertebral disc rupture in time. Congenital defect. During pregnancy and gestation a fetus develops all anatomical structures it will need during life. Defects of the spine can and do occur. Additional intervertebral discs can be formed. Some discs may form and then fuse together. The spinal cord can develop outside the spinal column. Intervertebral discs may develop in incorrect positions or at unusual angles. In some cases these defects can be very slight and cause pain after years of adulthood. Many of these "birth defects" are treatable a rare few are not. Tumors and infections of the back and spine. Most of these conditions are rare. The back obviously contains many sites where certain classic infections can take hold. 1) Meningitis is an infection of the spinal cord within the spinal canal. 2) Osteomyelitis refers to an infection of the bone. 3) Spondylitis involves an infection of the spine. 4) Tuberculosis of the spine. Rare today but quite common and still seen in medical case studies. 5) Cancer and tumors. Statistically the spine and its related bony structures are relatively low incidence sites for tumor growth and cancer. Tumors or growths can appear on the spinal cord itself which cause intense pain. Sometimes tumors developing in other areas of the body can cause "referred pain" into the area of the back and spine. Systemic diseases. Systemic means "system-wide." A systemic disease is not localized in one part of the body. A strong cold or infection with the flu virus is an example. Diseases such as hyperthyroidism (thyroid gland), hyperparathyroidism (parathyroid gland) and Cushing's disease (adrenal gland) are systemic metabolic diseases which can cause back pain. Curiously, certain vitamin deficiency diseases can produce back pain such as lack of vitamins A or C which causes the disease scurvy and lack of vitamin D which produces rickets. Aging and related hormonal imbalance. We all get older. The structures of the back react to this process in unique ways. The intervertebral discs loose flexibility, dry out and gradually become compressed and narrower. Treatment, exercise and understanding of proper therapy can slow down this process. In women, menopause and its consequential hormonal changes can cause osteoporosis or loss of bone mass. Also as one ages, senile osteoporosis begins which is a natural decay of bone structure and mass, regardless of sex. Referred Pain. Pains in the back can be caused by disease, infection or strain in another part of the body. Examples here are certain kidney diseases (because of their close proximity to the back,) pneumonia and, in women, a "tipped" uterus or womb. The reason why the pain from these conditions is felt in the region of the back is the close proximity of the nerve paths serving these organs or regions to the same nerves as those which serve the back. The brain mistakenly "translates" the pain as arising in the back because of the proximity of mixed nerves in the same region. Fatigue and Stress. This is the backache caused by stress or emotion. It can be completely psychological with no direct organic cause. Fear, mental stress from losing a job or spouse, or even having to pay the bills can cause this type of back pain. Simple fatigue, anxiety and overwork can also cause back pain when muscles serving the back become fatigued or occasionally lock in painful spasm when you are tired and or become anxious. This is the backache literally caused by the brain itself. This tutorial is merely a starting point! For further information on back care and back pain, be sure to register this software ($25.00) which brings by prompt postal delivery a printed, illustrated guide to back pain written by a physician plus two software disks. From the main menu select "Print Registration Form." Or from the DOS prompt type the command ORDER. Mail to Seattle Scientific Photography (Dept. BRN), PO Box 1506, Mercer Island, WA 98040. If you cannot print the order form, send $25.00 to the above address and a short letter requesting these materials. End of chapter. ---------- POSTURE, FATIGUE AND SPINAL CURVATURE ------------------------------------------------------------ This chapter includes general posture information as well as a "secret" to greater comfort for computer users who suffer from back pain. I have put this little secret towards the end of this chapter since you need to absorb ALL of it rather than seeking only a "quick fix" for your back pain. Improper curvature of the spine and poor posture are the largest sources of most back pain. In fact if you wanted to read only two chapters of this tutorial to achieve fast relief from back pain, this chapter and the chapters on exercises would probably provide the most immediate relief. Posture governs the relation of the body's structures whether we are standing, sitting or prone. Obviously the shape of the spine is related to the muscle groups and is of critical concern. Things are not necessarily what they appear to be when you examine the topic of proper posture. For example, when a person stands we often think of the old advice to "put your shoulders back and stand tall." Good advice? Not really. When you force your shoulders back, the stomach usually moves forward to counterbalance the effort. This results in excessive curvature of the frequently painful lower lumbar area. Not a terribly good idea for optimum spinal curvature and back support. When a person is in an erect standing position a more ideal posture would display reasonably slight bending of the primary and secondary curves of the back. Good posture would provide a mild lumbar (lower back) curve, abdomen and buttocks not prominent or protruding, and head carried erect with shoulders not sagging or rounded. Obviously weight and height would adjust this picture which is for the most part an ideal. A person with reasonably good posture is also less likely to suffer sudden or chronic trauma when lifting, sitting or driving a car. Good posture tends to distribute sudden or chronic load on the back EVENLY rather than CONCENTRATING damaging forces in one region of the back which leads to eventual injury. An ignored principle of physics... When you apply a force to a curved surface, the greatest force buildup or stress is exerted on the CONCAVE or inner curve of the surface. Thus the inner curves of a poorly positioned spine suffer the greatest wear and risk for injury. The spine has cleverly evolved with specialized primary and secondary curves to counterbalance most of the forces of our erect existence; however, excessive curvature and poor posture contribute to wear and tear due to this imbalance. If you sit or walk with slouchy shoulders, rounded back or flabby abdominal and buttock muscles you WILL sooner or later experience back pain. Posture extends to other activities such as sitting and sleeping. This requires muscle tone and for some folks a conscious decision to lose weight and do some exercises. No amount of surgery, pain medications or good intent can have as much benefit as these simple changes in posture mixed with a dash of simple spinal exercises. Just what is good erect posture? While standing or walking this involves lifting your head up and tucking the chin slightly which flattens the upper cervical curve mildly. The crucial lower back (lumbar) curve where most back pain occurs needs special attention. Usually this means tilting the pelvis forward slightly as you walk or stand by contracting the powerful muscles of the buttocks. Relax your buttocks too much and the pelvis tilts rearward and the lumbar curve increases rapidly. Some involvement by the abdominal muscles may be needed to help the buttocks achieve the proper tilt of the pelvis. Simply taking a walk for 15 to 20 minutes twice a day may painlessly increase the strength of the buttocks muscles. A conscious effort to try the specific back-strengthening exercises described elsewhere will accelerate the process. Head forward and high, pelvis tilted forward and buttocks tucked in. Things may be a little stiff at first, but the relief in pain should be worth it. Try it right now: stand, tilt your head forward and tilt your pelvis forward by tensing your buttocks. Hold the position for a good 30 seconds and you should begin to feel a little tingling, almost pleasant feeling as your spinal muscles "stretch and wake up." Now slouch back into the old bad position and notice the difference. Try to memorize the sensation of how it FEELS and repeat this "reminder" when you are standing at the supermarket checkout or waiting for an elevator, after a while it will become your normal correct posture. Practice and good muscle tone goes a long way to relieve back pain. The idea is to slightly flatten excessive lumbar (lower back) and cervical (neck area) spinal curvature. Back pains from all other causes such as trauma, pregnancy, disc injury and other causes are frequently traced to poor posture and spinal curvature which weakened the structure of the back and led to the related problem. In the study of back pain, posture really is the starting point. Here's a simple test to check your posture. Stand with your back against a wall and your feet about 10 to 12 inches apart. Bend your knees slightly and lean forward just a bit so that only your buttocks touch the wall. Now slowly tilt backwards so that vertebra by vertebra you flatten each inch of your back against the wall. As you start to press your middle back against the wall you will notice that the lower lumbar section tends to lift or pull away from the wall. Temporarily try to hold the lower lumbar section against the wall as you continue to press the remainder of your spine against the wall as well. Keep your knees slightly bent during this time. Finally straighten your knees and keep your back flat. Finally walk away from the wall slowly while you maintain this position for a few moments. Study the sensation. This posture is probably too exaggerated for most people to hold for very long, but it will give you an idea of the "feeling" of a more erect posture. A little exercise and conscious effort to maintain a more straightened, less slouchy posture goes a long way to relieve pain. What about sitting? Good posture suggests sitting in a relatively firm chair with your back snug against the back rest and both feet flat on the floor or slightly elevated. If you have a tendency to lean, it is better to lean slightly forwards rather than backwards since the latter increases the lumbar lordosis or swayback curvature which is so damaging and painful. The excessive curvature of the lower lumbar area or "swayback" inwards towards the stomach of is probably the most common damaging posture misalignment. Swayback sufferers tend to be unusually susceptible to lumbar (lower back) pain. Remember that the spine is a vertical stack of bony vertebrae each cushioned by a shock absorbing disc. When a swayback condition persists, the rear or back edge of each vertebra is forced closer together and, over time, nerves which lie in that region can be painfully compressed and add to muscle spasm. A painful "locking" or "catch" in the lower back may develop, commonly referred to as lumbago. Shooting pains can sometimes radiate downwards into the legs (sciatica) as the pain intensifies and the compressed nerves react. Swayback or excessive lumbar lordosis is a condition which obviously should not be allowed to persist for these reasons. It can usually be corrected by conscious attention to posture, and mild exercises to strengthen weakened muscles. When driving, sit close to the wheel so that your legs do not stretch out. Another trick which relieves back pain on long drives is to occasionally lift your left foot and rest it on the edge of the door-jam next to the driver's door. This slightly raises your left knee and surprisingly adds comfort. While you drive occasionally tense your buttock muscles and try to reduce the swayback curve of the lower back if it is sagging due to fatigue. Sleeping posture is also important. Unless specifically recommended by a doctor, NEVER sleep on your stomach. This exaggerates the lumbar curve of the lower back and is the worst sleeping position. A relatively firm mattress is recommended for most people. Waterbeds and overly soft mattresses usually are generally not good for the curvature of the spine. Especially if you suffer from back pain in the first place. The best sleeping posture is to lie on your side with both knees slightly pulled upwards and tucked together. A small pillow or towel between the knees can lesson the bony contact between each knee joint. If you must sleep on your back, a slight elevation of the knees is the preferred position and some people place one or two small pillows underneath both knees to elevate them properly and thus flatten the lower lumbar curvature. During the night you will move and toss a bit, but if you train your body to sleep either on your side or back (or a little of both), gradually this will be the position you will adopt and your back will be more comfortable in the morning. Speaking of awakening in the morning, another trick which is useful for some people is to try to do the back exercises we will present in a later chapter upon arising from bed and perhaps soon after a "warm up" shower. This is because in the morning the spine is at its greatest anatomical length and is most supple and flexible at this time of the day. Also, the spine is usually not fatigued and tense from standing or sitting all day. Try this wakeup idea and see if it reduces back pain for you. It may take one or two weeks to adopt to these "new" postures and exercise suggestions; but they are medically sound and your only recourse is more pain and intervention by a physician or surgeon. Back to standing posture. Most folks notice that after standing for extended periods of time gradually a lower (lumbar) backache appears and to a small extent an upper backache. This is almost ALWAYS caused by the gradual unconscious relaxing of the muscles of the buttocks and abdomen. You sag and slouch into a "more comfortable" position only to find it less comfortable in the end. A simple trick to avoid this if you must stand for long periods of time is to place a small stool or footrest in front of you and alternately put one foot or the other on the footrest as time passes. This small trick takes a little strain off the lower back and keeps the lumbar curve somewhat straight and thus prevents fatigue. Bars and taverns usually have footrests in front of bar stools because it is more comfortable on your lower back so you will usually stay longer and perhaps buy a few extra drinks. No kidding! Here is my "secret" to back comfort for those of you who spend a lot of time with computers. Computer users will do just about anything to alleviate back pain. It is our most constant complaint. Here is my unorthodox method to reduce backache: I frequently spend 8 to 10 hours daily working with computers. Obviously, I am a good candidate for backaches. First, I sit for perhaps half an hour in a good quality chair with my feet just slightly elevated, torso slightly leaning forward. After half an hour I move both my monitor and keyboard to an elevated platform (old piano bench placed on the desk) which sits to one side of my desk. I then stand with both feet on a shock absorbing pad and alternately move either my left or right foot onto a small footrest as I stand and type. Periodically (every ten minutes or so) I consciously tense my buttock and abdominal muscles to keep the lumbar curve comfortable and tilt the pelvis forward into correct position. The footrest and shock absorbing footpad go a long way to alleviating back pain and lately I spend about 40% of my time standing and typing and the remainder seated. I have found that these adaptations to life with the computer produce better attention, more work and are comfortable at the end of the day. Computing while standing has become a fairly comfortable regimen. It also has the advantage of allowing me two positions (seated and standing) from which to work rather than one. I usually find the standing position workable at the beginning of the day and gradually move into a seated position as the day progresses and fatigue sets in. But I still try to alternate between the two positions regardless of the time of day. Try these ideas yourself, but allow a week or two of "practice" to achieve pain reduction results. There are no fast cures for heavy computer users and office workers. Lifting and proper posture is a neglected topic. Most folks generally recall something about "lifting with your back straight." But there is a lot more to it than that. Generally locking your knees straight and bending from the waist to pick up anything is an invitation to to increase stress as the critical lower lumbo-sacral joint. The heavier the object, the greater the chance of stressing a muscle or joint either temporarily or permanently. To lift something heavy, squat to the floor, both feet about a foot apart and "hug" the object close to your body. One way to visualize this is to pretend you are hugging a small child who wants attention but does not want to be picked up - the child wants you to SQUAT and come down to its level. Keeping the object "hugged" close to the body minimizes the leverage applied on the lower back. Lift STRAIGHT up with the powerful leg muscles and NOT the back muscles. This is one procedure you should practice a few times when you can concentrate on the fundamentals and not when you have to lift a heavy truck tire in the pouring rain some dark evening. You have to discipline yourself to lifting properly since all of us unconsciously lift the wrong way (bending at the waist) because it is quick and easy. And dangerous. A few words about posture and women. Although a woman's pelvis is slightly wider than a man's, the principles are the same when is comes to a discussion about posture. During pregnancy, as we will discuss in a later chapter, the tendency of the lower back to bend into a "swayback" position with an exaggerated lumbo- saccral curve can be pronounced. Additional lower back exercises may be prescribed by a physician to bring the spine back to its normal curvature after the woman has given birth. Another sensitive area of discussion concerning posture concerns the formative teenage years during which some young women can develop psychological sensitivity and embarrassment about developing breasts to the point that a pronounced "slumping or hunching" of the shoulders takes place. This psychological reaction produces poor posture (shoulders slumped forward) to "hide" developing breasts and may unconsciously continue into adulthood. This posture adjustment can produce back fatigue and severe pain and should also be corrected by consultation of a woman or teenager with her physician. In most cases simple back exercises and posture adjustments are sufficient as corrections. Severe back pain has also been reported in medical literature as occasionally related to breast implants and their effect on posture. In these reported cases, women who have poorly conditioned muscles of the back, abdomen or buttocks suddenly suffer extreme backaches with the additional weight or size of enlarged breasts. The reaction is not metabolic or based on the immune system, but is simply mechanical fatigue of the back and lower lumbar region due to the additional breast weight. In most cases a proper exercise regimen will correct the back pain. This is obviously a sensitive topic but might be considered by some women and discussed with a physician. Curiously, shorter people tend to have the best posture and, on average, a lower frequency of back pain. Perhaps this is due to decreased weight loads placed upon the back which is inherently an unstable structure. This may also be due to the psychological tendency to "stand tall" as a mild psychological compensation for short stature. Tall people typically suffer greater chance of backaches. Additional posture-related diseases have also been reported in the medical literature. Poor posture can affect the primary dorsal curve of the upper back and the higher cervical curve of the neck region. This usually develops from the same poor habits of standing or walking with stomach protruding, chest in and buttocks muscles out of tone. If the primary dorsal curve in the upper back begins to curve strongly for these reasons it can negatively affect the cervical curve and lower lumbar curve as well. Excessive dorsal kyphosis describes this condition. Also associated with this defect in the dorsal curve is a condition known as Scheuermann's disease which, although rare, is noted most frequently in teenage males. It is not entirely clear if this disease is caused by poor posture, genetic defects, diet or if in fact the disease causes the poor posture. Another relatively rare disorder is scoliosis which does not affect the front to back curvature of the spine but the side to side or lateral curvature. This condition is found most frequently among teenage girls, as reported within medical literature. When seen from the front or back, the spine of scoliosis sufferers bends in an S shaped curve which may vary from mild to extreme. The cause of the disease is not entirely understood. Back braces and physical therapy are frequently prescribed. Surgical correction is also attempted in some cases and bone to bone vertebral fusion is the usual procedure. Historically, polio also caused some forms of scoliosis. If scoliosis is allowed to run its course in advanced cases, impairment of pulmonary (breathing) and cardiac (heart) functions take place as the chest cavity assumes a characteristic sunken shape and compresses internal organs. Good posture begins in two primary areas: the pelvis (controlled by buttock and abdominal muscles) and head (neck and shoulder muscles.) Align those two and the rest of the spinal structure usually falls into line. The lower lumbar region of the back usually causes the most pain, so it is the area to work on. This means exercise and conscious effort to strengthen these areas plus conscious posture changes. This tutorial is merely a starting point! For further information on back care and back pain, be sure to register this software ($25.00) which brings by prompt postal delivery a printed, illustrated guide to back pain written by a physician plus two software disks. From the main menu select "Print Registration Form." Or from the DOS prompt type the command ORDER. Mail to Seattle Scientific Photography (Dept. BRN), PO Box 1506, Mercer Island, WA 98040. If you cannot print the order form, send $25.00 to the above address and a short letter requesting these materials. End of chapter. ---------- TRAUMA ------------------------------------------------------------ In a previous chapter we touched briefly on two primary causes of back pain: chronic trauma and sudden trauma. Let's dwell for a moment on sudden trauma. Some injuries to the back may not result in an immediate fracture to the bony vertebrae but instead result in tearing of the muscles and ligaments or perhaps a rupture of an intervertebral disc. Sudden twisting, inappropriate lifting or a Saturday game of backyard football could be the culprits in these varying scenarios. Sudden pain is the usual result. The painful spasm of a muscle is one of the results of this sort of sudden trauma. In simplest terms, spasm is the sudden, rigid involuntary contraction of a muscle. The cause is usually a sudden trauma although it can also result from prolonged or chronic trauma as well, such as poor posture. These strained and "knotted" muscles hurt and seem to refuse any attempt at relaxation. In retrospect this "rigid reaction" to trauma may have been an evolutionary attempt by the body to "splint" or bind the injured area in a rigid manner to prevent further damage. However, if the spasm remains for too long it can produce more severe pain than the original injury and sometimes additional injury. Curiously, it is the weak muscle, lacking in tone or the over- tense, constricted muscle that can cause the most pain when sudden trauma occurs. A flexible, supple back is usually capable of withstanding sudden trauma. After surgery, bed rest and recovery from the traumatic episode sometimes involves strengthening and flexibility exercises which are usually prescribed by most physicians and orthopedic surgeons. Sometimes a physician will administer other treatments in an attempt to relieve pain resulting from sudden back trauma. Injections of Novocaine or Xylocaine anesthetics are possible. Cortisone injections have also been used with modest success in the past. Usually these injections are made directly into the muscle which is affected by spasm. The idea is to relax the muscle, discontinue the state of spasm and relieve the pain. These injections are not held to be completely effective by all clinicians. There is some disagreement in the medical community on the topic of muscle injections to relieve pain and promote healing in cases of back trauma. The use of hot or cold in the treatment of sudden trauma to the back is also an area of medical disagreement. One school of thought suggests that cold should be applied for the first 24 hours following injury to minimize swelling. After this mild heat should be used to increase blood flow to aid in in healing and reduce swelling. However deep tissue injuries in the case of sudden back trauma may have small amounts of bleeding or swelling in very deep layers of tissue which neither cold nor heat will reach, so the benefits are not completely resolved among all members of the medical community. If the pain is close to the skin, ice packs may deaden surface nerves and provide some relief from pain but little actual accelerated healing. The application of mild heat treatments to stiff or inactive muscles prior to exercise or physical rehabilitation is, however, usually a reasonable suggestion. Chronic trauma is the other category to be considered. Chronic means recurring injury or damage. Many sources have been identified as possible origins of chronic back trauma such as poor posture, disease, a gradually aging disc or even a bad mattress and sleeping position. Chronic trauma can also affect an area of the back which has previously suffered a sudden injury. Back braces and supports are sometimes prescribed in cases of chronic trauma. In certain injuries, a brace is an absolute necessity for proper healing or at least a return to normal function. However the continuous use of a back brace for treatment of chronic back pain is usually an unwise course - a bit like wearing a cast for a broken arm long after the arm is healed. In fact prolonged wearing of a back brace can allow further deterioration of weak back muscles which benefit from use, exercise and a full range of motion. Braces are more properly used to immobilize portions of the back following surgery or severe fractures. A better course of action in the case of chronic back pain, is sensible muscular conditioning and specialized exercises performed EXACTLY as recommended by a physician. Amazingly, even ruptured discs and deteriorating vertebrae are less painful when a proper regimen of physical reconditioning is attempted under the supervision of a physician and exercise therapist. Once an exercise plan has begun, it can usually be continued at home and at work with occasional monitoring by the physician. This tutorial is merely a starting point! For further information on back care and back pain, be sure to register this software ($25.00) which brings by prompt postal delivery a printed, illustrated guide to back pain written by a physician plus two software disks. From the main menu select "Print Registration Form." Or from the DOS prompt type the command ORDER. Mail to Seattle Scientific Photography (Dept. BRN), PO Box 1506, Mercer Island, WA 98040. If you cannot print the order form, send $25.00 to the above address and a short letter requesting these materials. End of chapter. ---------- THE "SLIPPED" DISC ------------------------------------------------------------ It seems frightening and sinister. A "slipped disc" sounds like what could be causing the nagging pain in your back. Somewhere you've heard that a friend needed extensive back surgery or manipulation to restore or reposition a slipped disc into proper position. A tidy explanation. However, as with most matters of a medical nature, a little science, history and anatomy often reveal a more accurate mixture of facts. In 1764 a malady named sciatica was described in the medical literature of the time. It referred to a sharp pain radiating downwards into the legs, frequently originating from the region of the lower back. By 1864 the terms sciatica and lumbago were associated in medical journals. The intervertebral disc was described in detail by the German pathologist Virchow in about 1855 who noted briefly a specimen which displayed a "tumor" or "swelling" he had observed protruding into the spinal canal from one of the intervertebral discs. Later the German physician Ribbert demonstrated that these protrusions were not tumors but were extrusions of the intervertebral disc tissue itself. By 1861 the French physician Sicard proposed a theory that sciatica might be due to pressure upon the nerve roots in the region now named the sciatic nerve. The Italian doctor Putti advanced the theory further by suggesting that the pressure or irritation might be due to intervertebral disc abnormalities or malformations. The chain of cause and effect was almost complete, but it was not until 1933 that a single cause was attributed directly to the afflictions of sciatica and lumbago. Doctors Mixter and Barr, American physicians practicing at Massachusetts General Hospital, finally drew the threads of information into a single coherent strand by linking the protrusion of intervertebral disc tissue with pressure on the sciatic nerve as the cause of the intense pain of sciatica. A word of caution. Not every manifestation of sciatica is caused by protruding or damaged disc tissue. However this is the most common source of severe back pain which radiates or "shoots" into the legs. Let's turn back a few pages and glance at the anatomy of the disc. The intervertebral disc is actually constructed of several tissues. Roughly oval in shape, it is composed of 1) top and bottom plates of gristle-like cartilage which are joined to the bony vertebrae, 2) the sides of the disc which are rounded and quite elastic. These layers of tissue are present in a radial layered arrangement like the belts of a tire. This makes them extremely tough. These layers comprise the annulus fibrous. Inside this disc "containment wall" is 3) the inner core of the disc, the nucleus pulposus, which is a white flexible gel-like tissue. Its function is to act as a shock absorber and force distribution mechanism. Technically only this pulpy core is the disc. If you hear that a disc has been removed during surgery, it is normally the inner nucleus pulposus which is extracted. As an aside, about 22% of the average height or length of the spinal column is due to the discs which provide both support and lateral side-to-side movement. Their design allows a fair degree of movement, but remember that the disc can only stretch so far before it ruptures. The outer walls of the disc are bonded directly to the vertebra and restrict their movement beyond certain limits. To understand the nature of a disc rupture you need to understand that the pulpy inner core of a disc acts like all hydraulic fluids. It can move, change shape and absorb shock but it CANNOT be compressed to occupy a smaller volume (at least at pressures normally present in the human body.) If the pressure becomes too great, the fluid will bulge outwards at a point opposite the compression. If a weak spot has been created in the outer containment of the disc, a rupture can take place. Sometimes the wall of the annulus merely bulges without actual escape of the nucleus pulposis. Other times the nucleus can also rupture. Once this happens the disc loses its value as a shock absorber because the pulpy core is no longer contained. It is important to note that the shock absorbing nature of the discs sometimes causes the bones of the vertebra to fracture first in cases of severe impact! Surprisingly some victims of car accidents or falls have fractured vertebra and scarcely damaged their discs - a testament to their excellent design and load bearing characteristics! A slipped disc, then, is not slipped at all but actually a rupture of the inner pulp of the disc either outwards away from the spinal canal or inwards into the spinal canal. In most cases the deterioration of the protective capsule of the disc is a gradual process which frequently begins at the rear portion of the disc. This is due to the fact that the wall of the disc is thinner there than the front of the capsule. A gradual softening or wearing down takes place in this outer disc wall. Then perhaps a sudden twist of the spine, a load improperly lifted or a fall causes a rupture to take place. This can produce the classic protruded disc. Frequently the bulge enlarges through the posterior longitudinal ligament of the spine and begins to press on either the spinal cord or the nerve roots which descend from it. Usually the protrusion will be slightly to the left or right side of the midline of the spinal canal which causes painful symptoms on only one side of the body. This single-sidedness of the pain is sometimes a diagnostic clue in cases of disc damage. Two separate types of pain are frequently reported by patients suffering from disc damage. If sensory nerves of the skin are irritated by the pressure of the ruptured or protruding disc, then the patient may report burning or tingling of the skin. If motor nerves supplying muscles are pressed by the protruding disc, muscles of the leg or back may go into uncontrollable painful spasm - classic sciatica. It is important to note that for all practical purposes the disc does not "slip" back into place and only rarely heals itself. The damage is permanent and does not heal completely. Eventually tissue scarring will begin to take place in the area of the protrusion which may further inflame nerve roots. If the pressure of the protruding disc becomes too great, nerves of the bladder and bowel may also be affected which almost always indicates surgical intervention. Lumbago is a different type of pain in which the back "suddenly seizes up." The muscles of the lumbar region go into rigid spasm and refuse to relax. The spasm may fade in a few hours or days. By lying perfectly still, the pain may be minimized and finally disappear as quickly as it began. Disc related pain may also produce another manifestation. Lack of activity of a disc-damaged back may cause recurring stiffness unless the back is kept supple with motion and exercise. The pain seems to be worse with inactivity and will diminish when the person moves around a bit. This may also reflect both true arthritis as well as a form of arthritis caused directly by long term disc degeneration. Treatment for mild disc protrusion is relatively specific. Initially some physicians may prescribe bed rest, since standing increases the pressure on the damaged disc. Pelvic traction may be initiated while a patient lies in bed. The function of the traction is not to pull or stretch the spine, but to tilt the pelvis and reduce the curve of the spine which relieves some pressure and produces comfort. Pain medications and some muscle relaxants might be prescribed by a physician. X rays would be taken along with some blood tests. After one or more weeks of bed rest or traction some standing might be permitted with no sitting allowed. Back strengthening exercises would gradually be added to build muscle tone. This course assumes surgical intervention is not attempted. In more severe cases, a myelogram or NMR scan would be done to confirm substantial disc protrusion and probable need for surgery to remove the inner core of the disc. After surgery the space within the disc gradually fills with scar tissue. In time, and with some patients, the space between the two vertebrae may gradually grow together in a type of spontaneous bone to bone fusion which lessons mobility and further damage at that area of the spine. After disc surgery, rehabilitative exercises are prescribed to build up the muscles of the back so that proper support is maintained. The topic of surgical fusion, the deliberate joining of two or more vertebrae after disc surgery, is controversial. Some physicians routinely fuse vertebrae after a disc operation, others fuse on a more selective basis. Usually small pieces of bone from the hip or other area of the body are grafted directly between vertebral bodies to limit their motion and provide support. This technique is generally the most severe course of action and is usually reserved for the extreme cases of disc degeneration. It also performed for other diseases such as spinal bifida, a birth defect. So far we have discussed problems usually seen in the lower lumbar region of the back. However, the cervical discs of the neck region can occasionally be affected. Arthritis is a common culprit here. Symptoms can involve radiating pain into the shoulders, arms and hands. In severe cases of cervical disc rupture or degeneration weakness of the arm and hand muscles will be seen and "tingling" or even complete loss of sensation in the skin of the hands and arms. Again this is caused by pressure on sensory or motor nerves in the area of the cervical region of the spine. Cervical disc problems are more frequently seen in older people since these complains are more commonly arthritic in origin. Cervical disc protrusion can be more serious than lumbar disc problems since a large section (more nerves) of the spinal cord is present at this level of the spine. Bed rest, traction and neck braces or cervical collars are usually attempted in milder forms of this disc problem. The bottom line, however, in dealing with disc disease is that a weak back is unstable and prone to disc disease and injury. Proper exercise and posture can go a long way to preventing disc disease in the first place and minimizing its impacts. This tutorial is merely a starting point! For further information on back care and back pain, be sure to register this software ($25.00) which brings by prompt postal delivery a printed, illustrated guide to back pain written by a physician plus two software disks. From the main menu select "Print Registration Form." Or from the DOS prompt type the command ORDER. Mail to Seattle Scientific Photography (Dept. BRN), PO Box 1506, Mercer Island, WA 98040. If you cannot print the order form, send $25.00 to the above address and a short letter requesting these materials. End of chapter. ---------- ARTHRITIS ------------------------------------------------------------ Arthritis would probably be placed third on any list of backache causes. Chronic back strain and disc disorders would earn first and second place respectively, but arthritis affects some people and for a variety of reasons, both mechanical and metabolic. Osteoarthritis is the most common of the three arthritic afflictions of the back. It is a reflection of the gradual wearing out of the spinal column. Over time the joints of the back wear. The process can be accelerated by faulty posture or chronic strain, but the end result is the same. In one scenario leading to osteoarthritis a disc can begin to bulge outwards due to pressure or chronic strain. Eventually one of the connective ligaments may be lifted free from the surface of two adjoining the vertebral bodies. As time passes, this injured site fills with "bone spur" growths which eventually join to fuse the two vertebrae together. Once natural fusion takes place, the discomfort is somewhat lessened, but while the damaged space is filling with the new bone spurs, grinding and pain is felt. Other types of osteoarthritic growth can occur and this is only one example. Since the lower lumbar region and upper cervical region of the back have the greatest range of motion naturally, it is these regions that frequently show the first signs of osteoarthritis. Treatment may consist of one or a combination of the following: bed rest, exercise therapies, pain killers and surgical spinal fusion. Rheumatoid arthritis is the second type of arthritis which can afflict the back. It is not a mechanical problem like osteoarthritis but a true disease and is much more serious. It is not necessarily limited to the old, but can be found in all age groups. Frequently it begins in the large joints of the body and may spread to other joints. The spine may be affected in later stages. The pain and inflammation of the joints may also involve a gradual loss of bone mass, termed osteoporosis. Ankylosing spondylitis or Marie-Strumpel disease is quite rare. It has characteristics of some arthritic conditions. Gradually the intervertebral joints of the spine are replaced by bone. Eventually the entire spine may become rigid. The primary dorsal curve of the back can become acute as leaving the victim with a severely bent back. Surgery is the primary method of treatment and can affect only modest restoration of function. Gouty arthritis is the third arthritic condition which can affect the back. It is seen infrequently in medical literature today. It is a true metabolic disease involving uric acid crystal buildup within the joints. The first joints to feel pain are usually those of the foot and toes, although the spine can also be affected. A blood test, X rays and appropriate medications can usually identify and manage this type of arthritic condition. It is most frequently seen in males. ------------------------------------------------------------ SYSTEMIC DISEASES ------------------------------------------------------------ Systemic diseases, in simplest terms refer to diseases or infections which are "system wide" or throughout your body. Unlike localized back ailments such as chronic strain or a slipped disc, these diseases can produce backaches and pains from the perspective of their overall impact on the body. Specific metabolic diseases, those that affect your metabolism or endocrine balance, can cause back pain. The endocrine system secretes hormones directly into the bloodstream. The pituitary gland at the base of the brain, for example, secretes growth hormone. Too much of this growth hormone and you end up becoming either a giant or a dwarf. Three systemic endocrine imbalances can affect the spine and bones of the back... Hyperthyroidism is a disease of the thyroid gland located in the neck. It controls the rate of bodily metabolic functions. Hyperthyroidism refers to the "hyperactive" state of this gland when it secretes too much hormone. When the rate of metabolism is speeded excessively, calcium can be gradually removed from the bones, frequently those of the spine. The individual vertebrae begin to lose bone mass and density and can become collapsed or misshapen. This obviously leads to back pain. Hyperparathroidism refers to the small parathyroid glands which are located in pairs on either side of the thyroid gland. When these four glands become hyperactive a similar calcium depletion can take place in the bones of the vertebrae, but in a non- uniform, irregular manner. Gradually gaps are created in the vertebrae and other bones. A fibrous tissue fills in the gaps. The bone becomes irregular and weakened. Surgery may be required reduce back pain in severe cases. The third primary metabolic disease which can affect the spine is hyperadrenalism or Cushings Disease. In this instance excessive cortisone is present in the bloodstream caused by hyperactivity of the adrenal glands located near the kidneys. Gradually osteoporosis or loss of bone mass begins. Frequently in the bones of the spine. Metabolic diseases can also affect the spine other than endocrinological imbalances. Paget's disease is also known as osteitis deformans. In this situation the bone mass of the vertebral bodies begins to rapidly grow and thicken. Usually this involves the bones of the lower spine. The tiny holes through which nerve roots emerge, the foramina, begin to narrow. Pressure is placed on spinal nerves which become irritated by the compression. The disease is confirmed by a blood test for enzyme alkaline phosphatase. The cause of the disease is not fully understood. Surgery is frequently the only remedy. Diseases of the circulatory system can also affect back pain. If a blood clot forms which partially blocks oxygen and nutrients to muscles of the legs or buttocks severe pain can result which mimics back pain. The pain is referred to the area of the back and spine, but nonetheless originates from blockage of blood to muscle groups in the leg. Thrombophlebitis, an inflammation of the veins, can also cause backaches which can be referred to the back and spinal region. Likewise arterial obstructions and classic varicose veins can cause pain which is referred to the back region. On a mundane level, infections such as a common cold can also cause backaches. A system wide viral infection lowers your threshold of pain and tends to produce fatigue in joints and muscles. Mild muscle spasm can result and as a consequence backaches are not uncommon when you have a cold. A practical solution is to encourage bed rest and keep those knees bent which reduces strain in the lower lumbar region of the back. This tutorial is merely a starting point! For further information on back care and back pain, be sure to register this software ($25.00) which brings by prompt postal delivery a printed, illustrated guide to back pain written by a physician plus two software disks. From the main menu select "Print Registration Form." Or from the DOS prompt type the command ORDER. Mail to Seattle Scientific Photography (Dept. BRN), PO Box 1506, Mercer Island, WA 98040. If you cannot print the order form, send $25.00 to the above address and a short letter requesting these materials. End of chapter. ---------- AGING AND HORMONAL CHANGES ------------------------------------------------------------ All living things grow old. The spine is not immune to the process and in fact ages more rapidly than other parts of the body. One of the trademarks of the aging process is the gradual dessication or drying out of body tissues. It seems odd that a man or woman will live comfortably to an age of 80 yet begin to show signs of spinal aging in the early twenties. However, at that early age it can be demonstrated that the intervertebral discs are starting to lose their flexibility and moisture content. Aging has begun. This may be due to our genetic makeup as well as the relentless force of gravity constantly pressing on the unstable upright spinal column. The discs, as we learned from an earlier chapter, comprise about 25% of the length of the spinal column. As aging takes place they gradually become compressed, lose moisture and shrink. Joint motion, flexibility and all-important shock absorbing qualities gradually diminish. Chronic spinal strain thus begins. These mechanical stresses are transferred to the vertebrae, supporting muscles and ligaments. The ligaments holding the structure together may be pulled or lifted from the vertebral surfaces which in turn attempt to minimize the instability by creating bony spurs or growth projections to fill the missing spaces. This can eventually lead to osteoarthritis as the spine shrinks in overall length. A classic and for the most part inescapable fact of aging. However if the supporting muscles and structures of the spine are kept in good shape with judicious exercise habits, the pain and loss of flexibility is minimized to a certain extent. In the back and spine, as no other site of the body, the truism "use it or lose it" has clear and absolute meaning. Osteoporosis or osteopoenia can be a side effect of aging. Gradually the bones can become brittle and spongy, thus losing critical bone tissue mass. Normal bone tissue is not a static, dead tissue. It may seem dead and brittle, but it is definitely not dead. A constant turnover of bone calcium and other tissue takes place at all times within bones. One perspective is that every bone in your body is replaced, molecule for molecule, every 6.5 years. Bones also react to stress and fractures - healing and bonding together to reproduce the original load bearing characteristics and also enlarging slightly along the axis of stress. Put a bone under pressure and, within limits, it will attempt to grow stronger and deposit additional calcium to counteract the stress. Astronauts in the gravity free environment gradually lose calcium. In a sense gravity is both friend and foe: it provides the stress which keeps bones strong yet it eventually collapses and compresses our upright spinal column. A biological paradox at best. Bone has two primary anatomic structures: 1) matrix, the protein "sponge" into which calcium is deposited and hardened. 2) An intercellular tissue which fills the hollow pores of the matrix with solid calcium salts - a sort of glue which binds the tissue and calcium together. The matrix onto which calcium is deposited is produced by osteoblast cells. Meanwhile another variety of cell, the osteoclast, reabsorbs bone which has aged and must be removed. Thus two opposing forces are at work governed by different cells: one deposits bone mass, the other removes it. Usually the chemical and cellular forces are in balance. However when the osteoclasts gain the upper hand, more bone is removed than is replaced. This is the mysterious mechanism which is the basis of the disease osteoporosis. However we need to go a little further to learn about the specific dynamics of this process and how it affects the spine. The outer portion of bone is hard and is called the cortical layer. The inner core is softer and spongy and is known as the cancellous layer. The inner cancellous layer is the region where dynamic chemical and cellular activity takes place. Calcium salts are moved around, primary blood cells are generated and a host of other process occur within this bone core area. And this is the central clue why the vertebrae of the spine seem to be uniquely prone to osteoporosis, certain infections and some tumors. It is because a LARGER region of the vertebrae is CANCELLOUS (soft tissue - dynamic cell reactions) than cortical (relatively stable - slow chemical turnover). Because of this important difference, the bones of the spine are much more easily disturbed by chemical, hormonal or metabolic imbalances in other parts of the body. In this respect, the structure of the vertebrae of the spine are dramatically different from bones in the other parts of the body. Why do these vertebral bones have this unique structure? Some anthropologists speculate that our own evolution is to blame. Our rapid adoption of an upright posture REQUIRED the bones of the spine to become more cancellous and dynamic in cellular activity to allow for an unstable and inherently risky upright spinal posture. Nature and evolution simply did the best it could given the short time frame needed to adopt an upright posture! A particular hormonal imbalance, usually associated with the menopause of women, has been linked statistically to osteoporosis. Apparently the shifting tides of hormones produced at menopause can lead to gradual thinning and spongy weakening of the vertebral bones whose uniquely dynamic and chemically sensitive cancellous core is susceptible to the hormone triggered event we call osteoporosis. X rays conclusively reveal the weakening of the vertebral bodies in osteoporosis. The attempted treatment, although by no means conclusively successful, is hormone replacement therapy. Frequently this means administration of both male (testosterone) and female (estrogen) hormones. Calcium tablets and vitamin D may also be prescribed. The benefit of this method of therapy is open to debate among members of the medical community, although it is usually attempted as the the best available treatment for now. Hip fractures in elderly patients have also been reduced by providing vitamin D and calcium within an enriched dietary plan. In the case of senile osteoporosis, a variation not related to menopause, different hormones are usually administered along with calcium and vitamin D tablets. The results are also not clearly demonstrated, but are nonetheless frequently attempted. Once vertebral collapse occurs, back braces or surgery may be required. Bed rest is not always the treatment to use in this situation because once bed rest or disuse sets in, the spongy vertebrae begin to deteriorate rapidly. Lack of use tends to accelerate the process of bone loss in most conditions involving osteoporosis. Bones need a certain amount of use and exposure to gravity to keep calcium deposits in place. Bed rest can accelerate calcium loss. One malady related to osteoporosis is the gradual expansion of the intervertebral discs into the upper and lower plates - the roof and floor - of the bony vertebrae themselves. However, if the vertebrae have already lost most of their elasticity, this likelihood is diminished. Unlike a disc rupture which takes place either into the spinal canal or outwards towards the lateral side of the spinal column, disc expansion can take place directly into the weakened mass of the vertebral body itself in cases of osteoporosis. ------------------------------------------------------------ INFECTIONS ----------------------------------------------------------- Infections and tumors of the spine are rare indeed, but worth mentioning in any discussion of maladies which affect the spine. The advent of modern antibiotics has erradicated many spinal infections, but nonetheless prudent physicians consider and test for the presence of spinal infections when other causes cannot be assigned. Tuberculosis is usually associated with a severe infection of the lungs but has been reported in medical literature to also infect the vertebrae of the spinal column. The bacteria which causes tuberculosis is easily carried in the blood stream and can take up residence in the spongy core of the vertebrae. Since the bacteria cause slow growing abscesses and eventual formation of scar tissue, patients may eventually report loss of motor or other nerve function as the spine is compressed or pinched by the encroaching scar tissue and gradually collapsing vertebral bone mass. In severe cases of tuberculosis of the spine, partial or complete paralysis of the lower body has been reported if spinal nerves are severely affected. A low grade fever, common with most bacterial infections, is an early manifestation. Profuse sweating at night, back pain, vomiting and a limit in the range of motion of the back may follow. A chest X ray may show no evidence of lung involvement. A biopsy with a hypodermic syringe is the conclusive laboratory test for presence of infection. This procedure removes a small quantity of fluid from a suspected spinal abscess which is sent to a medical laboratory for positive identification of the tuberculosis bacillus. Surgery and spinal fusion is the corrective method of choice in advanced stages of the disease. The bacteria which infects the spine selectively attacks the bone mass of the vertebrae and seldom involves the flexible discs since they do not contain oxygen and blood which the bacteria requires for growth. A serious outbreak of antibiotic-resistant tuberculosis began to surface in early 1992 and was reportedly seen in New York and regions of Florida. Although initial reports suggest it is primarily linked to tuberculosis of the lungs, spinal involvement may evolve as the bacteria spreads into the general population. New antibiotic compounds are currently under investigation to treat this unusually virulent form of tuberculosis which could eventually cause a new pandemic and reversion to earlier methods of treatment such as sanitorium care and strict isolation. Meningitis refers to an infection of the spinal cord. A variety of bacteria and virus organisms have been implicated as causing this serious disease. Symptoms include, but are not limited to, stiffness of the neck and spine and painful spasms. The meningoccocus bacteria, a common cause of meningitis, may also cause fever. However, viral organisms causing meningitis may not always produce fever. The early stages of meningitis may begin as simple back pain. A common diagnostic test is for the physician to test muscle reflexes in the lower extremities. If specific lower body reflex sites are hyperactive (overly reactive to touch), meningitis is a strong suspect. Polio, or more properly poliomyelitis, involves similar viral infection of the spinal cord. However, common anti-polio vaccines have almost erradicated this disease in the United States, but it does continue to surface in parts of Africa and remote regions of the World. Spondylitis is a bacterial infection of the spine usually involving the common staphylococcus bacteria which may be carried to the site of the spine by the bloodstream. The vertebral bones are usually infected and the bacteria may spread from one vertebrae to the next. Back pain, fever and loss of appetite may be present in spondylitis victims. X rays of the vertebrae in early stages of the disease may show little evidence of infection, but as the bacteria grow, X rays and biopsy (drawing infected fluid from the vertebra with a hypodermic needle) provide conclusive identification of this bacteria. Antibiotics are usually able to halt the spread of the infection. Surgery may be required if the vertebrae have been severely damaged or contain large abscesses. ------------------------------------------------------------ TUMORS ----------------------------------------------------------- Discussing tumors immediately brings to mind a sinister word: cancer. However it is important to note that cancer applies to malignant or spreading tumors which invade and destroy healthy tissue and bone. Benign tumors generally do not spread throughout the body, can be removed by surgery and may present little actual tissue damage. Thankfully, tumors both benign and malignant of the spine are relatively rare. Malignant tumors are generally divided into two classes: Primary and secondary. Primary tumors originate in a specific tissue or bone. Secondary tumors, also known as metastatic tumors, have spread to a specific tissue from another primary site of origin. The most common sites where primary malignant tumors begin are the prostate gland, breast, lung, kidney and thyroid. These are the classic sites where the majority of cancers originate. Primary malignant tumors may eventually involve bone, especially the large bones of the spinal column and lumbar vertebrae because of their spongy, blood rich cancellous core which was discussed earlier. Diagnostic methods to determine the primary or original site of the cancer are frequently undertaken by a physician and may involve tests such as X rays of the lung, thyroid studies with radioactive materials, pyelograms of the kidney, mamograms of the breast, ultrasound studies of the prostate and biopsy of the spine. Treatment may involve a combination of radiation, chemotherapy and hormones which is directed at the primary or original site of cancer growth. Treatment of the secondary site may involve a similar or modified treatment with radiation and chemotherapy as well. Malignant tumors can involve areas other than the bones of the spine. Liposarcomas and fibrosarcomas are malignant tumors of fatty tissues and muscles of the back respectively. Schwannoma is a malignant cancerous invasion of the spinal cord. Malignant tumors of the spine are usually secondary - they have spread to that location from another part of the body. In fact the first sign of cancer in another part of the body, the prostate or kidneys for example, is the presence of back pain which results from the invasion of the cancer to the bones of the spine or soft tissue of the back from its primary site. Some physicians note that if back pain increases when the patient lies down, a tumor may be a probable culprit - although this simple clinical observation must be corroborated with additional tests. Other than the secondary tumors we have discussed, a few primary tumors of the spine have also been detailed in medical literature. Several rare types have been reported: 1) Osteogenic sarcoma, a rare and extremely deadly form of cancer which grows rapidly. 2) Multiple myeloma which reflects an abnormal rapid growth of bone marrow cells. 3) Chordoma which is usually slower growing and may confine itself to localized areas of the spine. Chordomas can be surgically removed with moderate success, but can recur with time although their growth and reappearance is slow. Sarcomas are usually fast growing and more resistant to surgery, radiation and chemotherapy - and thus among the deadliest of tumors. This tutorial is merely a starting point! For further information on back care and back pain, be sure to register this software ($25.00) which brings by prompt postal delivery a printed, illustrated guide to back pain written by a physician plus two software disks. From the main menu select "Print Registration Form." Or from the DOS prompt type the command ORDER. Mail to Seattle Scientific Photography (Dept. BRN), PO Box 1506, Mercer Island, WA 98040. If you cannot print the order form, send $25.00 to the above address and a short letter requesting these materials. End of chapter. ---------- PREGNANCY AND BACK PAIN ------------------------------------------------------------ Pregnancy and childbirth is a special time for all women. In the short space of nine months a variety of hormonal and physical changes take place leading to the eventual birth of a child. Physicians wisely suggest a series of exams, tests and counseling for all pregnant women. Adjustments to diet, exercise and work habits are usually suggested. For most women it would seem that back pain is one of those inevitable side effects of pregnancy. Something that is simply to be endured as a necessary consequence of the process. Surprisingly, however, there is much more to the situation. Not only can back pain be managed with an active exercise regimen, but also it is wise to consider that ignoring back pain as inevitable may lead to chronic back strain, disc damage or other permanent injury after pregnancy has passed. The possibility of back pain and even spinal damage should make a woman spend some time with her physician and ask questions about her backaches as well as her diet before, during and after pregnancy. In the early stages of pregnancy strong hormonal adjustments begin within the body of the now expectant mother. Fatigue, the need for additional sleep, and nausea or classic morning sickness may become apparent. The spine and lower back posture begins to change and become more relaxed. The muscles of the abdomen and back relax under the forces of hormonal control, gravity and for some women the effects of previous poor posture. The lumbar curve begins to accentuate slightly and the pelvis begins to tilt backwards. This new posture begins to play on the weakened and now fatigued lower back muscles which may display mild painful spasm - the first sign of a nagging backache in early pregnancy. As the baby grows and the abdomen protrudes, the forces of both gravity and hormonal changes continue to relax the muscles of the back and abdomen and a pronounced "swayback" appearance begins to appear. The stresses on the lower back muscles and spine increase and backache frequency may dramatically rise. Muscle spasm and pain may rise accordingly if no correctional action is taken. As the delivery date approaches, dramatic changes take place as new hormones are produced which loosen the ligaments of the pelvis so that it may expand and allow passage of the baby through the birth canal. A side effect of this late hormonal burst is that not only the ligaments of the pelvis are relaxed, but also ligaments in the nearby lower spine are allowed to become more flexible. This hormonally-driven joint relaxation is non-selective and affects joints other than those in the pelvis. The lower spine loses additional support and the lumbar curve becomes even more distorted which can further increase backache and muscle spasm. A direct cause of back and lower leg pain during pregnancy can also derive from the increased size of the baby itself. The large fetus can place pressure directly on the nerves of the lumbar area causing direct pressure and immediate pain. The nerves passing though the area of the psoas muscle which serve the lumbar region are especially subject to this source of pain. Vein congestion from the added pressure of a large fetus can also be a source of lower leg pain. Finally, the possibility of a ruptured disc is present in women who are overweight or have poor muscle tone or other pre-existing spinal disorders prior to pregnancy. Sometimes the structural weaknesses induced by pregnancy do not completely return to normal after the birth of the baby. If poor posture, excessive weight and poor exercise habits are allowed to continue, the back problems brought on by pregnancy can become chronic, organic and permanent. Some women who have had minor backaches prior to pregnancy or borderline spinal instability and muscle weaknesses may find that after pregnancy back pain may become a way of life. In most of these cases the pregnancy did not cause the back pain, it simply aggravated pre- existing poor posture and muscle tone thus providing the "straw that broke the camel's back." It is especially important that a woman clearly inform her physician of ANY prior back pain as early as possible during pregnancy. Special exercises, posture adjustments and even back braces are available. Diet and adjustments for rest are usually the first things on a woman's mind during pregnancy, but chronic back pain may be the most painful symptom of pregnancy which is neglected by a woman in discussion with her physician. For most healthy women simple exercises and posture adjustments are all that is required to further strengthen the back and abdominal muscles for the return to normal posture after the baby is born. The coccyx, the small vestigial tailbone at the end of the spine, can create unique problems and special pains during pregnancy. By function, the ligaments of the coccyx are directly attached to the bones of the pelvis. The additional weight of the fetus and other hormonal changes produce an unusually high amount of pressure and stress to the ligaments of the coccyx during pregnancy. During labor in the hospital delivery room the pressure on the ligaments of the coccyx increases further. Immediately after delivery this normally silent area of the spine may present severe pain for many women. The pain quickly disappears as the stretched ligaments and joints mend and reposition themselves into normal alignment. However, it may become difficult for a post-delivery mother to lie directly on her back if any pressure is placed on the area of the coccyx. Treatment depends on the severity of pain. Most hospitals and physicians suggest a small pillow, warm water bottle or donut shaped pad for relief of pressure on the coccyx if a woman must lie on her back. In cases of severe pain, injections of pain relieving medications are prescribed. Cortisone injections have also been used to alleviate pain in this area. In most cases the pain subsides and the damage is not permanent. In rare cases, systemic disorders have been found in pregnant women who complain of lower back pain. Osteomalacia is vaguely related to osteoporosis which was discussed in an earlier chapter. In simplest forms it is a vitamin deficiency. The normal treatment is to administer additional amounts of both calcium and vitamin D. In a sense, this disease is an obscure form of adult rickets. It affects primarily the bones of the pelvis and lumbar area. In severe cases the weakened bones of the pelvis may indicate Caesarian section delivery of the baby since the malformed or twisted bones of the pelvis do not permit easy passage of the fetus during birth. This disease, largely a dietary deficiency, is rare among American women whose diets are reasonably balanced. Osteitis condensans is another unusual disease which can sometimes affect pregnant women. It is unusual since its primary manifestations may be aggravated by pregnancy. The changes brought about by this disease are seen in the sides of the pelvis within the two bones of the ilia which become hard and thickened with calcium buildup. The normal porus matrix structure of the ilia is dramatically altered and the bones become firm and dense. Cause and cure are largely unknown at this time. Pain medications are at present the only relief. The excessive buildup of calcium seems to accelerate with each pregnancy and in some cases of this condition, caesarian section may be the preferred method of delivery. Back pain can be a manifestation of this condition which is relatively rare for most pregnant women. ------------------------------------------------------------ BIRTH DEFECTS ------------------------------------------------------------ A variety of other conditions can also give rise to back pain. Congenital and developmental problems, while rare, can occur before or after a child is born and in specific instances can increase the risk of backache and back pain for the child. Spondylolysis is a unique developmental defect of the back which involves the upper and lower articular facets of the vertebrae. In simplest terms this junction between two vertebrae must precisely match for smooth motion and good structural stability. In this condition a section of the articular facets may be missing and thus poorly aligned. Gradually a gap forms and the empty space is filled with a type of soft cartilage. The site of the defect is frequently in the area of the sacrum and fifth lumbar vertebra - a classic candidate for backache. Since the tissue which fills this missing gap is softer than bone, the misalignment can be significant enough to give rise to a secondary condition termed spondylolyisthesis which refers to the actual movement or slippage of the vertebrae out of proper alignment. The fifth lumbar vertebrae is most frequently affected by this condition which is not purely congenital (present at birth) but probably begins after a child is born. The condition usually deteriorates during the teenage and adult years as the fifth lumbar vertebra slips out from the support of the sacrum below. The disc between these two bones becomes stretched and in time the sciatic nerve may also become involved leading to a sharp pain radiating into the legs. Surgical correction via fusion of the fifth vertebra and sacrum is sometimes attempted in severe cases of this condition. Fortunately this condition, like many congenital and developmental conditions is relatively rare. Spina bifida describes a congenital defect in the development of the fetus growing within the mother's womb. You will recall that the bones of the vertebrae enclose the spinal cord like a protective shell. During embryonic development the rear or posterior portion of the vertebral bones are the last to form and surround the spinal cord. If closure is incomplete during the final stages of spinal development, sections of the delicate spinal cord may remain outside the protective vertebrae along with its covering membrane shroud known as the meninges. A protrusion or sac may form around this nerve tissue and extend directly through the skin of the back and be visible at birth. The exposed portion may be relatively short or long. When extensive portions are exposed, nerve function may be lost in the lower limbs, bowel or bladder. Obviously surgery and substantial medical care is required in cases of spina bifida involving substantial spinal cord damage or exposure. Spina bifida can also be present as smaller defects which do not cause exterior swelling and are relatively minor. In many cases an individual may go through life not realizing that a portion of vertebrae does not completely enclose the spinal cord. The structural integrity of the spine is nonetheless compromised and potential instability is present which may lead to eventual backaches and pain. Typically the lumbar and sacral portions of the spine are most commonly affected in cases of spina bifida. A minor defect may not be apparent even upon X ray examination of a child under the age of six or seven years old. After this age, the defect is more easily diagnosed by X ray or NMR (nuclear magnetic resonance) examination. Occasionally a small pimple or darkened hairy wart may appear at the base of the spine on the skin to mark to defect. Eventually, as the child grows, the structural instability of the spine in this area may lead to backache or pain. Surgery to fuse or repair the defect may be attempted to restore function and reduce pain in cases where spina bifida leads to chronic back pain or potential nerve damage. Some medical journals report that the undetected occurrence of small spina bifida defects in the general population may be as high as 14%. Congenital defects can occur in other ways as well. Normally the lumbar area of the spine consists of five vertebrae. Sometimes the vertebrae develop but do not properly separate, thus leading to congenital vertebral fusion. In other instances only four vertebra develop. Medical literature has also reported six and even seven lumbar vertebrae developing. Finally the articular facets, the bony "projections" or "arms" which extend from the sides of the oval vertebrae may develop poorly and protrude from the vertebrae at unusual angles. Back pain and backaches may thus arise and in some cases surgical intervention may be required. This tutorial is merely a starting point! For further information on back care and back pain, be sure to register this software ($25.00) which brings by prompt postal delivery a printed, illustrated guide to back pain written by a physician plus two software disks. From the main menu select "Print Registration Form." Or from the DOS prompt type the command ORDER. Mail to Seattle Scientific Photography (Dept. BRN), PO Box 1506, Mercer Island, WA 98040. If you cannot print the order form, send $25.00 to the above address and a short letter requesting these materials. End of chapter. ---------- BACK PAIN EXAMINATION AND DIAGNOSIS ------------------------------------------------------------ A visit to the doctor's office is an event filled with anxiety. The fact that the visit is in connection with your back pain makes it even more troublesome. Could it be cancer? Is a disc ruptured? Could I have meningitis or tuberculosis of the spine? What will happen to my job and work schedule if I have to go into the hospital? The good news, however, is that the diagnosis and treatment of back pain has been significantly advanced in recent years by a variety of new imaging methods and diagnostic tools which can determine the source of your back pain quickly and reliably. Unlike an obscure tropical disease, back pain today is usually diagnosed quickly and accurately. But the first step is always an examination by a physician. Although the format of an office exam varies depending on the doctor, the content remains roughly similar with some parts of the following "ideal" exam omitted by the clinician and other parts added or enhanced. The state of medical technology and the pattern of arriving at a logical medical diagnosis varies from patient to patient so do not be concerned about the exact sequence of events which are outlined below. Typically the physician will consider the following methods to arrive at a diagnosis of your specific back pain 1) a physical exam to determine normal back movement and limits 2) circulatory exam 3) neurological exam 4) X rays 5) exam of reproductive system if warranted 6) advanced imaging methods and diagnostic tests if warranted. The first step prior to the examination is for you to assemble prior patient records, X rays and lab tests which have been done to assess your back pain. Perhaps your family physician has previously ordered chest and back X rays and done a limited orthopedic examination and then referred you to a specialist. Maybe members of your family have a history of ruptured discs or back injuries. The more information and background you can assemble before the examination, the more quickly and accurately the physician can arrive at a diagnosis. Also take the time to jot down the history and description of the back pain. Did it begin on the job? Is it a chronic problem? How long has the pain been with you? Does it worsen when you stand, exercise, bend or lie down? Do weather or temperature changes affect the pain? Does warmth or cold relieve the pain? Do you drive long distances or sit at a desk all day? What types of exercise and sports do you engage in? Is your exercise regular or weekend in frequency? What medications do you take? Use words like sharp, dull, burning or stabbing to describe the pain. Do you smoke or drink alcohol? How would you describe your family and home life? How would you describe your current level of stress and emotional state? Is the backache or pain getting better or worse? Did you have meningitis as a child? Any other childhood diseases? Are the pains localized in your back, legs, neck or combinations of the above? Do the pains shoot into your legs and what movement or position causes the pain to move into your legs? Have you visited a chiropractor, physical therapist, acupuncture specialist? Have you had previous back operations? What home remedies have you tried? Do you have any infectious diseases such as tuberculosis? What is your job and how do you move your back during the day as you perform that job? Take a moment to assemble the answers to these questions before the office visit. Surprisingly the answers to these questions may lead the physician to immediately consider the exact range of tests which will confirm the source of the pain. After these preliminaries, the physical examination takes place. Normally the patient wears only a gown and may be asked to perform various movements either partially or fully unclothed so that the physician can note the movements and relative positions of your legs, back, neck and torso. Many physicians ask the patient to initially perform various movements and changes in posture without touching the patient. After this initial phase a "hands on" exam at the examination table usually follows. As you stand quietly before the physician he or she may begin by looking for clues. Is the posture and lordosis (curve of the lower back) within normal limits? Is the spine straight or curved? Are there any bends laterally to the side (a diagnostic hint of scoliosis?) Do the legs seem of nearly identical length? Are the shoulders stooped or straight? Any malformation of muscles? Next, usually without touching the patient, the physician requests a series of motions or activities to be undertaken. You may be asked to walk normally forwards and backwards. In addition you may be asked to walk on your tiptoes and then again on the heels. Do you have fallen arches/flat feet? Can you hop on one leg then the other? Can you twist and bend forwards, backwards and side to side? Can you bend and touch your toes without pain? You may be asked to maintain the position(s) in certain cases. The physician may ask you to comment on the presence or absence of pain during some of these simple exercises and movements. Information is now flowing to the physician and he is beginning to eliminate a some possible causes and consider others. Muscle spasm, vertebral disc status and nerve compression or irritation can be inferred from results of these simple tests. For example, a ruptured disc may cause pain when bending from side to side. Compounding the problem can be an overlap of symptoms among patients having both arthritis and disc ruptures. The next stop is usually to sit on examination table for a brief test of reflexes - tapping knees and ankles with a rubber hammer. This can reveal quite a bit about nerve compression and health in some back injuries. Next you may be asked to lie down on your back on the exam table for leg, calf, thigh and buttock comparative measurements. The reason for this is that damaged muscles which are infrequently used due to pain can atrophy, shrink or lose tone when a single muscle is compared to its "twin companion" muscle on the other side of the body. Some physicians may follow these tests with nerve checks by lightly touching or probing the skin of the leg, foot or calf with a pin or pointed object. The reason for this is that nerve roots which pass through the lumbar region of the lower back serve these extremities and if the nerve has been pinched or damaged in the vicinity of the spine, loss of sensation may be apparent in areas of the body served by those nerves. An adjunct to these nerve tests are related tests of muscle strength and tone. For example, the physician may ask you to lift, extend or pull a leg, foot or toe in a specific direction while he attempts to keep it in position. Conversely he may try to move a toe, leg or foot while he asks you to resist. This will tell the doctor about the condition of a nerve which passes through the lower back and the muscle tone of the extremity in question. Frequently the knees, ankles, and hips are tested for any sign of nerve damage by extension and retraction with resistance offered by the hand of the doctor. Routine blood circulation tests are also performed by checking skin color in the legs, back and buttocks. Pulse is checked in these regions. Blockage of blood flow in the leg may give rise to back and upper leg pain especially in the elderly. Still lying on your back, the doctor will probably instruct you to keep your knee straight as he slowly lifts your leg and foot from the table. A high angle of leg elevation in this position indicates healthy hamstrings and, if little pain is present, little likelihood of sciatic nerve pressure and ruptured disc injury as the cause of back pain. Conversely, tight hamstrings and pain in the lower back and buttocks are usually consistent with the possibility of disc injury. By the way, tight hamstrings are associated with back problems in general which speaks to the positive effect of an exercise program in preventing backaches. The doctor may next bring one or both knees and thighs close to your chest. For most people this should not be painful, but some types of back injuries can cause additional pain in this position and the doctor will note this. Hip joints are usually rotated in and out and extended to assess any painful positions and potential nerve or hip damage. Older patients are more prone to hip injuries and fractures - sometimes both back and hip injuries are found together in these patients. You will usually be asked to lie on your stomach while still on the exam table as the doctor directly feels along the length of your spine, kidneys and rib cage. He may press or tap and note both sound and sensation along the length of the spine. The kidneys will be probed and examined. Kidney pain is often confused with spinal pain in many patients. The pelvis will be felt and examined for pain. Ligaments, facets of the vertebrae and muscles along the spine are usually palpated (probed) by hand for tenderness or sign of injury. The doctor may ask you to tense or clench your buttocks. In some cases of nerve damage or pain, one of the two buttock muscles may be smaller or softer then the other during this maneuver and the difference between the two will be noted. Disc ruptures and nerve damage are sometimes suspected by loss of muscle tone localized on one side of the body - a valuable clue to a medical professional. A gynecologic exam may be requested for women, and this is usually performed by the woman's gynecologist rather than the orthopedic specialist or internist. For men a prostate exam done manually with the gloved physician's hand and/or also by newer ultrasound methods may be requested. Infections, tumors and other abnormalities of the reproductive organs sometimes are manifested in lower back pain. Laboratory blood tests are not normally done for the majority of back pain patients since muscle, bone and disc problems are usually the source of most back pains. However arthritis, infections and some tumors can be detected with blood tests. If a physician suspects one of these conditions, a blood chemistry profile group, blood count and ESR sedimentation test may be ordered. A blood count simply measures the number and concentration of white and red blood cells. If white cells are increased the patient may have an infection. If red cells are decreased, the patient may be suffering from anemia. The blood chemistry profile checks uric acid, phosphorous and calcium levels. Results of this test can reveal significant data about overall metabolism, possibility of gout as the cause of back pain and other indicators. The ESR sedimentation test reveals the general state of the body's immune system and the presence of unidentified infections. In addition, other blood tests can reveal the presence of certain forms of arthritis which can affect the spine. Most back pain patient will undergo a routine X ray of the spine. These standard X rays are normally used to reveal shape and curvature of the spine, compression of intervertebral discs, suggestions of arthritis, spondylosis and congenital abnormalities such as spina bifida. By themselves, X rays are not useful for conclusive diagnosis of soft tissue damage such as disc rupture. Similarly, the narrowing of space between two vertebrae may suggest the collapse of a disc, but the X ray does not produce an image of the soft tissue disc itself. A more specialized type of X ray image, the MRI (magnetic resonance image) also known as NMR (nuclear magnetic resonance) may be ordered to provide high resolution images of soft tissue structures such as the discs and spinal cord. NMR does not involve X ray radiation, but instead relys on high level magnetic and radio frequency pulses to produce a soft tissue cross section image of the area of study. This test is relatively expensive and only available at larger hospitals or special imaging centers. A computer processes the pulses of energy from the magnetic field and radio frequency beams as they pass through the patient to produce remarkably clear images of soft tissue. Another test which may be ordered is a CT (computerized tomography) also known as CAT scan which likewise produces images of a cross-sectional area of the body. Unlike NMR it uses X ray beams and is useful for imaging ruptured discs, vertebrae and the spinal canal. However it is limited in resolution and because of its X ray imaging method produces better images of bone and solid tissue than the NMR imaging method which is superior for soft tissue. In comparison to NMR imaging, CAT is less expensive but does require the patient to receive a small amount of X ray irradiation. A bone scan is another diagnostic test which may be considered for some patients. During this test a small amount of slightly radioactive dye is injected into the blood stream. Several hours after the injection, the patient is placed on a table or bed above which a radioactivity detector or sensor is slowly moved to detect accumulations of the radioactive material. Normal bone cells pick up or collect measurable amounts of this special radioactive material. Bone cells which are abnormal or dead may pick up little of the material. Finally, bone cells which are diseased, healing from fracture or hyperactive from tumor growth pick up extra amounts of the radioactive material. This "map" of concentrations of the radioactive material can thus reveal unusual bone cell activity or lack of it and thus assist in diagnosis. Arthritis of the spine, tumors and old fractures can thus be revealed by this diagnostic method. A myelogram is another test which may be suggested for some back pain patients. An injection of X ray dye is made into the spinal canal. This is normally done in the hospital on an X ray table or bed. After the dye has entered the spinal canal, X rays are taken. In most cases the patient will be tilted or rotated to allow the dye to flow upwards or downwards in the spinal canal. Additional X rays are taken after movement of the dye to a new area within the spinal canal. It should be noted that NMR or MRI imaging produce nearly the same or better detail than this method and for that reason the myelogram is gradually becoming less popular than the non-invasive NMR imaging exam. However in difficult diagnosis, the myelogram still has unique diagnostic value. A variation of the myelogram takes advantage of the fact that since the dye is designed for X ray detection, some physicians order a CAT scan following the myelogram to enhance the CAT image. The myelogram dye in the spinal canal is eventually absorbed by the body and excreted in the urine within a few days. Excellent images of the spinal canal are obtained by this method and are quite useful to a physician in diagnosing some types of back pain. A diskogram is an imaging method which examines a specific intervertebral disc. An X ray dye is inserted by needle directly into a disc which is suspected as damaged or ruptured. If a rupture has taken place, the X ray image of the dye will tend to flow out of the central core of the disc towards the area of disc rupture and thus reveal the presence or absence of disc injury. The test is obviously done under the control of a radiologist and placement of the needle is precisely located within a single disc. The EMG test does not involve X rays or imaging methods but is instead a test of nerve condition. Electrically conductive wires are inserted directly into a specific muscle and measurements are made of electrical activity. Damaged, spastic or injured muscles provide unique "signatures" of activity which are shown as tracings on graph paper. Thus the health of a specific muscle can be examined reliably. A nerve conduction test also uses electrical sensors to measure muscle activity, but in this case attempts to determine the speed at which a nerve impulse travels down a nerve path to or through a muscle. The time is takes for the impulse to travel can be graphed and nerve and muscle health or damage can be deduced from this data. This tutorial is merely a starting point! For further information on back care and back pain, be sure to register this software ($25.00) which brings by prompt postal delivery a printed, illustrated guide to back pain written by a physician plus two software disks. From the main menu select "Print Registration Form." Or from the DOS prompt type the command ORDER. Mail to Seattle Scientific Photography (Dept. BRN), PO Box 1506, Mercer Island, WA 98040. If you cannot print the order form, send $25.00 to the above address and a short letter requesting these materials. End of chapter. ---------- BASIC BACK EXERCISES ------------------------------------------------------------ Everything have read in previous chapters of this tutorial has led up to this chapter which might more aptly be titled DOING SOMETHING ABOUT BACKACHES Before describing the basic exercise regimen, several paragraphs to set a precautionary tone. Always seek the advice of your physician before attempting ANY exercise program aimed at relieving backaches. Why? There are many reasons. People who have osteoporosis are strongly advised by most physicians to AVOID back flexion exercise movements. Likewise you may have a disc rupture, damaged spinal cord or undiagnosed case of spina bifida. Simply lying on an exercise mat or the living room carpet to "try a few exercises" to see if the pain is reduced is unwise! From another perspective, you may have a serious condition that warrants professional medical attention and the following exercises may provide temporary relief from pain which masks or hides a deeper organic condition. I do not mean to frighten you - the majority of back pain sufferers, perhaps 85% or higher, need only exercise and stretching movements. Statistics are on your side that exercise will produce a personal "cure" for your backache. However, play it safe and check with a doctor for clearance on the following exercises which are commonly suggested by many orthopedic surgeons and family physicians. Having said that, we should talk about the "when and how" of back exercises. For most folks exercise in any form begins with the best of intentions and then fades in both intensity and motivation as the demands of a job, family and other interests begin to pile up. Back pain exercises are different - once you start you MUST stay at it or the pain will return. Back pain exercises are like brushing your teeth: a lifelong commitment. Remember that the spinal column is by design unstable and largely held together by muscular effort especially in the lower lumbar region. The muscles which stabilize the spine and back quickly degenerate from lack of use. "Use it or lose it" is an apt warning when it comes to back exercises. These exercises should be done slowly and thoroughly without rushing and for many people the best time to do them is early in the morning just after rising and perhaps after a warm shower to further relax and prepare back and abdominal muscles for a mild workout. Upon arising in the morning, your body will feel rested and your spine will be flexible and at its greatest length due to 8 hours of rest in a prone position in the absence of gravity compression effects. This is an optimum time for a spinal exercise session. Most of the exercises are done on the floor. A carpet or towel is all you need. You need to relax and do each exercise deliberately and slowly WITHOUT bouncing! Do NOT hold your breath during any exercise! Light breathing or panting will keep you from straining muscles as a workout proceeds. If you have the time in the evening a light "mini-session" of the same exercises prior to retiring adds a bit of extra spinal flexibility, muscle tone and is an aid to restful sleep. The printed back pain guide which accompanies this tutorial illustrates in photographs and drawings many of these exercises and is suggested if you are serious about relieving your back pain. Registered users of this software receive this printed guide which also includes other rsearch and comments. Many back pain patients report surprising relief from pain within the first week during which they have begun the exercises. However it normally requires several weeks to fully restore muscle tone to abdominal, and buttock and back muscles which are weak. Evaluate results at the end of the third week and draw your own conclusions. After a day or so of exercise sessions, you may notice pain relief lasting for about 30 minutes to an hour. As time goes on and the workouts continue, pain will usually diminish further. Of course, you must augment these exercises with posture adjustments and other lifestyle changes mentioned in earlier tutorials for the whole "system" to have full effect. Go back and review the posture chapter of this tutorial for tips to protect your back as the exercise routine unfolds. Let's begin... Exercise one: Pelvic tilt. The is the most basic and ESSENTIAL exercise to learn. Lie on your back. Bend your knees and keep your feet flat on the floor. Your knees should be about six to eight inches above the carpet and in this position most back pain sufferers are quite comfortable. Keep your knees bent. Tighten your stomach muscles and squeeze your buttocks tightly together. You should notice your lower back flatten against the carpet. More importantly you should consciously notice that your lower pelvis tilts up. Take small short breaths if necessary but DO NOT try to hold your breath. Try to hold the pelvic tilt position. Another way to describe this maneuver is to attempt to flatten your back while you "thrust" your LOWER pelvis upward. The two muscle groups to involve are buttocks and stomach. Relax and repeat three to five times. Hold for the count of 5 to 15 seconds if possible on each "thrust". The "hold" is absolutely essential to the process of strengthening the necessary muscle groups. As you gain proficiency in this maneuver see if you can repeat the same exercise standing (bend your knees slightly). A further enhancement in the lying position is to see if you can slightly raise your buttocks off the floor. As you stand and go about your activities during the day, try to consciously tilt your pelvis forward using the buttock and stomach muscles. This is how the lumbar region is SUPPOSED to be supported in the first place! Here's another tip: remember in a previous chapter we talked about putting a small stool under one foot if you have to stand for long periods of time? Try this and then study how this maneuver automatically encourages a pelvic tilt. The basic pelvic tilt is the key to controlling lumbar (lower back) pain. Exercise two: Hamstring stretch. Lying on your back assume a pelvic tilt position with both knees bent as in the previous exercise. Next bring ONE knee up and finally straighten that leg towards the ceiling and finally stretch your heel - point your heel - towards the ceiling. If you cannot straighten out or point towards the ceiling - and most folks initially cannot - take your time and try to at least extend in that direction. You will feel a stretching and mild pulling behind your knee as your hamstring wakes up. Hold for the count of five then lower the leg. Switch to the other leg. Repeat 5 to 10 times. Exercise three: Knees to chest. Start in the basic pelvic tilt position. Slowly and evenly pull both bent knees to your chest - or as close to your chest as is comfortable. Hold for the count of five then release and repeat five additional times. Keep breathing slowly and gently - don't strain. This exercise is EXTREMELY important. Exercise four: abdominal crunch/sit-ups. Go back to the pelvic tilt position. Gradually tilt and roll your head and chest up and towards your knees. Try to touch your knees with your hands but do NOT allow your back to become fully erect in a sitting up position. Do not attempt a full sit-up since this usually results in rapid bouncing up and down without much real muscle effort. Concentrate on holding the "crunch" position for a few seconds and then down. Repeat five times. The purpose of this modified sit-up is to work on those abdominal muscles. Exercise five: Leg cross overs and trunk rotation. Back to a pelvic tilt position. Extend your right leg flat on the floor. Keep left leg bent slightly. Now lift your extended right leg up and over the left leg and try to stretch it to the left side as far as you can go but try to KEEP your upper and middle back flat on the floor. As your pelvis lifts gradually you will feel a twisting rotation and STRETCHING in your back. Do not extend your leg too far, you just want a gradual rotation you can hold for four or five seconds. Repeat with the other leg extending in the opposite direction. As you limber up you may be able to touch the extended leg to the floor. Exercise six: Spinal twist. A slightly stronger spinal twist than the last. Lay on back, knees bent. Pelvic tilt position. Hands behind the head. Elbows touching floor. Cross your bent right knee over the left bent knee - pretend you are sitting cross-legged on a chair - and then slowly let both legs drop to the side with a resulting twisting motion to the spine. Try to keep upper back and torso relatively flat on the floor as you twist the lower back. You may not be able to let both knees touch the floor but you will feel a stretching and twisting sensation which you should do slowly. Hold for the count of five and then reverse the legs and twist to the other side. Exercise seven: Back arch. Roll over on your stomach and get into a position as if you were going to give a small child a pretend horseback ride. Your weight rests on your two knees and two hands. Now arch your back up like a cat as far as is comfortable and hold for the count of five. Use stomach and buttock muscles to help. Then relax your back and sag for a second like an old swayback horse. Repeat five or six times. This will increase flexibility and continue back muscle exercises. A very worthwhile exercise. Exercise eight: trunk stretch while seated. A good exercise to try in the morning but VERY good to USE throughout the day during work. Sit near the edge of a chair. Legs spread apart. Cross arms over chest. Make sure chair will not slip or slide backwards and then tuck chin down and curl your trunk downwards as if you are trying to touch your head to the floor. Hold for the count of five and repeat five or six times. Stretches the spinal column and muscles. Exercise nine: rotational sit-up. A tough but profitable exercise. Lying on floor on your back do a pelvic tilt. As you begin a traditional sit-up/abdominal crunch described previously, instead rotate to the right or left side letting your weight rest on right or left shoulder. Raise opposite shoulder off the ground. Curl head forward and hold. This produces a twisting effect on the spine and works on abdominals at the same time. A tough exercise but highly recommended. This tutorial is merely a starting point! For further information on back care and back pain, be sure to register this software ($25.00) which brings by prompt postal delivery a printed, illustrated guide to back pain written by a physician plus two software disks. From the main menu select "Print Registration Form." Or from the DOS prompt type the command ORDER. Mail to Seattle Scientific Photography (Dept. BRN), PO Box 1506, Mercer Island, WA 98040. If you cannot print the order form, send $25.00 to the above address and a short letter requesting these materials. End of chapter. ---------- ADVANCED BACK EXERCISES ------------------------------------------------------------ The basic exercises in the previous chapter will begin to attack the source of most backaches. But as with most plans, the body is the sum of its parts and a general exercise program to increase overall body strength and cardiovascular output from the heart and lungs goes further to enhance life and freedom from pain for a back pain patient. In addition, more difficult back and spinal exercises are also presented in this chapter. Many physicians who treat back pain sufferers recommend a comprehensive exercise program in addition to specific back and spinal conditioning. What sports and exercises are best? On the preferred end of the scale, the following sports and exercises are generally save for back pain patients. Note that for the most part these activities feature CONTINUOUS motion, LOW IMPACT potential and MILD TWISTING AND TORSION to the lower back and torso: 1) Walking briskly for twenty to thirty minutes daily. 2) Bicycling with legs fully extended and minimum crouch. Be careful lower back is straight and free from "swayback" position or excess lordosis. 3) Swimming using low stress strokes such as the crawl or sidestroke rather than butterfly stroke or diving. No sprinting. 4) Rowing if allowed by a physician. 5) Stair climbing machine. 6) Cross country ski simulation machine. Sports activities NOT generally encouraged for back pain patients normally have the potential of EXCESSIVE IMPACT OR EXCESSIVE TWISTING AND JERKING. They are also less than perfect as aerobic exercise since they are not continuous. For example, you undergo an intense burst of energy while running and batting during baseball followed by longer periods of general inactivity. The same is true of most of the other activities on the following list of activities NOT recommended: 1) Football 2) Golf 3) Tennis 4) Bowling 5) Skiing 6) Baseball 7) Basketball 8) Horseback riding 9) Soccer 10) Hockey 11) Weight lifting. As an aside you might wonder which exercise the author has chosen. An avid bicyclist, I take advantage of several hilly roads near my home for my cardiovascular workout. My circular "loop trail" is merely 5 miles long. It first takes me on a scenic winding two mile flat road which later turns up an extremely steep hill about one third of a mile long. Finally the hill returns me to another flat road and the final stretch home. The entire loop takes about twenty minutes and features a nice warmup sitting on the bicycle followed by a standing position on the bicycle as I climb the hill (almost simulating a stair stepping machine in posture) and then a pleasant "cooling off" sprint home and a return to a sitting position on the bicycle. The reason I like my personal routine is that it is a fast and intense workout. Joint stress and impact is low. Maybe not your cup of tea, but the important point is that it is convenient as a daily routine and that is the secret to making it work! Additional advanced back strengthening exercises are also available for back pain patients. Again, these should be attempted ONLY with permission of a physician. Continuing our list from the previous chapter... Exercise ten: hamstring stretch. A classic runner's warmup maneuver, but invaluable as an advanced exercise for patients who can do the earlier basic exercise group without pain. Stand facing a desk, chair or low table. Place left heel of foot on edge of table or chair. Place a hand on your extended knee for balance and concentrate on keeping your back straight. Now gradually bend your right leg so that your body begins to lower. You will feel a pulling sensation in your hamstrings. Keep the extended left leg and knee straight. Be careful to slowly do this exercise and do only a few repetitions at first so you cause only a mild stretching sensation. Overdoing this one can cause a lot of pain, so experiment slowly and carefully. Exercise eleven: chin and knee touch. Lay on your back on the floor. Extend right leg and knee straight and allow it to lie on the floor. Bring left knee up to your chest by gradually pulling it with both hands. Roll your head towards your knee and try to touch your chin to the knee. Hold for the count of five then reverse the process with the other leg. Five repetitions. Exercise twelve: scissors. Lie on your back and extend both arms out to side for balance. Lift legs and thighs into the air. Knees may be slightly bent. Slowly and deliberately using thigh muscles, "scissor" right leg past left leg and then spread legs apart. Repeat and "scissor" left leg over right leg. Your legs move from side to side as they cross over each other. Five repetitions. Exercise thirteen: hyperextension of lower back. This exercise should only be done with doctor's permission and for those who have previously built up their back strength from earlier exercises. Lay on your stomach. A small flat pillow under the abdomen may help perform this exercise. Place both hands behind back. Keep feet on floor and raise your head and upper chest off of the floor. Hold for the count of five. Do five repetitions. Exercise fourteen: crossovers. Very similar to the previous exercise, but instead of lifting upper body, first raise BOTH the right arm, head and OPPOSITE left leg. Hold for the count of five then switch to raise of left arm and right leg. Exercise fifteen: leg raise. Lay on abdomen as in last exercise, but raise and hold both legs while keeping chest and torso on the ground. You may need to shift the pillow to a position under your hips rather than under your stomach. Hold the extension for the count of five. Repeat five times. This tutorial is merely a starting point! For further information on back care and back pain, be sure to register this software ($25.00) which brings by prompt postal delivery a printed, illustrated guide to back pain written by a physician plus two software disks. From the main menu select "Print Registration Form." Or from the DOS prompt type the command ORDER. Mail to Seattle Scientific Photography (Dept. BRN), PO Box 1506, Mercer Island, WA 98040. If you cannot print the order form, send $25.00 to the above address and a short letter requesting these materials. End of chapter. ---------- HOME REMEDIES ------------------------------------------------------------ What should you do when you need FAST relief from a sudden back spasm or painful backache? What home remedies and course of action helps during a backache attack? What other lifestyle changes might reduce back pain and strain? Backaches tend to be a matter of degree and intensity. Sometimes the pain is mild with only a sense of stiffness. Other times quite severe. It may be worse when bending or may only happen when your back is cold. One indicator to watch for is the sudden onset of pain which radiates down into the foot or lower leg which could clearly indicate the presence of a ruptured disc. However, if the pain remains localized to your back or upper thigh, the chance of disc rupture is lower - not zero, just lower. If you fear that a ruptured disc is the source of the pain head for bed immediately, call the doctor and try to curl up on your side with your knees pulled up and bent. But let's back up a step. What course of action should be taken for various degrees of back pain which come on suddenly? For mild back stiffness and pain take aspirin or tylenol if you are allergic to aspirin. Avoid all but VERY brief periods of sitting or riding in a car, sleep on a firm mattress on your side or back with knees elevated by a pillow. Do the pelvic tilt and other mild exercises twice a day to ease muscle stiffness, place a warm water bottle beneath your back before exercises and while at rest on your back. Avoid bending, lifting, overstuffed or soft chairs. Eat while standing and work while standing, if possible. For severe back pain consider the following. Contact your physician immediately. Take aspirin or tylenol for pain in the dosage recommended by your physician. Ice packs for ten to fifteen minutes the first 24 hours of the attack may decrease pain and relieve muscle spasm; check with physician if this is advisable. Do not overchill skin or back. After the first 24 hours ask physician if application of mild heat is allowed to relax muscle stiffness. Attempt to stay in bed while you lie on your side or back with knees elevated. Get out of bed only for VERY brief trips to bathroom. Take warm showers and NO sitting baths. Watch for signs of numbness in toes or lower legs. Watch for signs of fever by checking your temperature. Avoid ALL sitting for the first week. Avoid back exercises for first four to five days until pain and stiffness has subsided. After that time try pelvic tilt and light knees tucks to chest. Follow up with second visit to physician. Determine a recommended back exercise or therapy program in consultation with physician. Another simple home remedy for mild back pain is to lie on the floor on your back and place both legs in an elevated position on the seat of the chair. Thus the knees are bent and the pelvis is slightly tilted reducing some back strain. In fact any resting position on your back which allows the knees to be bent and the feet elevated reduces back strain. A small warm water bottle under the small of the back for short periods reduces muscle spasm and may further reduce the pain. Any time you put a water bottle under your back be sure to wrap it in a towel and use only a small amount of warm water so that the water bottle remains relatively flat. Your back cannot remain flat while you lie on a water bottle the size of a balloon. Keep the water bottle flat! Some people report relatively rapid relief if a corset or back brace is worn for a few days following an attack of back pain. This is usually fitted to your back by a physician or physical therapist. But remember that the back brace is merely stabilizing a weakened spinal column and for the most part preventing supporting muscles from developing healthy tone. However if a physician tells you to wear a back brace or corset for an extended period of time - such as in the case of disc rupture or specific surgical recovery, by all means follow your doctor's instructions. If arthritis is also a compounding cause of your backaches, aspirin's strong anti-inflammatory effects are usually beneficial in reducing joint inflammation. As an unusual twist, try doing a few of the back exercises like the pelvic tilt and knees pulled to chest maneuver laying on your back in the bathtub partially filled with warm water. You will be surprised at the extra flexibility and relief from pain you can get exercising in a warm bathtub. Are there special foods or vitamins which have been implicated in correcting backaches? Vitamin A or C deficiency can cause scurvy and a type of back pain. Vitamin D deficiency causes rickets and consequent back pain. Osteoporosis has been connected with vitamin D and calcium imbalance. For the most part, though, these are specific vitamin-linked problems, not overall dietary problem patterns found among most back pain patients. Some research has indicated that Vitamin E in its role as anti-oxidant may slow some forms for joint deterioration, aging and pain in adults. Dehydration or lack of water can cause some existing joint and disc problems to flare up painfully. About the best that can be said from a sensible dietary standpoint is to drink additional water - 6 to 8 glasses per day and perhaps take two or three ordinary vitamin tablets per week if you are concerned about your diet and back pain. It may not help, but it certainly cannot hurt. Consider wearing flexible shoes or sneakers for several weeks after an attack of back pain. Women's high heels are notorious for causing back pain and a change to different footwear permanently may further reduce chances of back pain. Also check for worn out heels and soles which may slip or provide improper support and cause falls and other types of back injury. The role of shoes and back pain has been established. When in doubt try wearing tennis shoes for several weeks and see if back comfort is increased. When sitting for long periods of time, consider stretching your legs, wiggling your toes and finding a way to put one or both feet on a footrest. As you sit, try to contract your stomach and buttock muscles and tilt your pelvis every ten minutes despite your sitting condition. Most people unconsciously cross their legs while sitting which is simply an attempt by the body to tilt the pelvis and raise one leg higher than the other. You don't cross your legs because your leg becomes more comfortable, but because your BACK becomes more comfortable! However, crossing your legs while you sit is no substitute for a footrest and occasional stretch break. As mentioned in earlier tutorials, try adjusting your work schedule to alternate between standing and sitting positions. When you stand, shift one foot then the other on a six to ten inch high footrest. As you stand, try to do a "mini" pelvic tilt by slightly bending your knees, tensing your buttocks and thrusting your lower pelvis forward. Do this three or four times an hour and hold the tilt position for about ten seconds. You can even do this in a supermarket checkout line since the maneuver is barely perceptible and is a matter of merely a slight bending of knees and tilting of hips. Also consider the statistics or "odds" that you will have backaches and take corrective action: tall people are prone to backaches as are overweight people. Pregnant women and women during and after menopause are also prone to back pain. Office workers and computer users who sit for long periods of time are frequently backache patients. If you are in a risk group for backaches, use these tutorials to trace the most probable cause and consult with your physician on a course of action. This tutorial is merely a starting point! For further information on back care and back pain, be sure to register this software ($25.00) which brings by prompt postal delivery a printed, illustrated guide to back pain written by a physician plus two software disks. From the main menu select "Print Registration Form." Or from the DOS prompt type the command ORDER. Mail to Seattle Scientific Photography (Dept. BRN), PO Box 1506, Mercer Island, WA 98040. If you cannot print the order form, send $25.00 to the above address and a short letter requesting these materials. End of chapter. ---------- SURGERY, MEDICATION, CHIROPRACTIC MANIPULATION AND OTHER FORMS OF MEDICAL INTERVENTION ------------------------------------------------------------ Back pain responds to changes in posture and exercise, but other medical treatments are sometimes considered by patients. Surgery, chiropractic therapy, medications and injections are sometimes suggested to back pain patients. A brief background regarding these paths is probably in order.... Doctors of chiropractic and osteopathy attempt to manage back pain and several other medical ailments by manipulating the spine, joints and muscle tissues in an effort to relieve pain and restore nerve function. Chiropractic practitioners may also make recommendations regarding diet, exercise and rehabilitation therapies. Some surgeons and physicians consider forceful manipulation dangerous and of dubious benefit. Others consider it one of several possible beneficial therapies. The truth probably lies somewhere between the two views: it may have potential but within specific limits. The name chiropractic derives from the Greek language and roughly translates as "practice by hand." Chiropractic medicine was founded in 1895 by Daniel David Palmer of Davenport, Iowa - a town which is also home to the Palmer College of Chiropractic. By profession Mr. Palmer was a grocer who was interested in the possibilities of manipulation in the maintenance of health and relief of pain. As proposed by Mr. Palmer, certain diseases and specific pain have origins in pressures placed on the nervous system. The restoration of normal function and relief from pain could be achieved, he believed, by manipulation and treatment of the structures of the body - especially the spinal column and back. If pressure upon a nerve pathway is present, nerve impulses are believed to be blocked to and from the brain which causes the tissues served by these nerves to become more susceptible to disease and pain. Disorders believed to be treatable by this system, according to practitioners of chiropractic, can include lumbago or back pain, high blood pressure, asthma and arthritis. In chiropractic theory, dislocations and subluxations of the vertebral bones cause pressures upon associated nerves which leads to pain and decreased resistance to disease. A subluxation is described as a partial separation or slippage of two joint surfaces while a dislocation is the complete separation of both sides of a joint, frequently with tearing or rupture of the joint capsule. Fourteen chiropractic colleges are accredited in the USA and Canada to award the doctor of chiropractic degree. Students normally begin study with at least a high school degree and in many cases an additional two year liberal arts college background. Training during a four year chiropractic college normally includes courses in chemistry, neurology, X ray diagnosis, anatomy and clinical practice. Currently all 50 states of the U.S. license chiropractic practitioners. Medicare, Medicaid and workers compensation usually covers the cost of certain chiropractic treatments. Osteopathic doctors are also skilled in manipulation but unlike chiropractors have attended a four year medical school of osteopathy which is similar to mainstream medical training. In most cases osteopaths are licensed to practice medicine like an M.D. Chriropractors are licensed to perform manipulations of the body, back and spine and are limited for the most part to that type of service. Chiropractic manipulation cannot push or move a ruptured disc back into proper alignment - once a disc has ruptured it is permanently weakened. Likewise a chiropractor cannot treat meningitis, tuberculosis of the spine or tumors of the spine. A herniated or ruptured disc cannot be treated by manipulation and may even be dangerous if manipulated improperly. Surgery may be the only course of action for cases of severe disc rupture. Chiropractic practice has limits and reasonable practitioners admit this. Mobility and recovery from muscle spasm and joint facet problems may, however, be benefits of manipulation. Beware, though, that overly frequent chiropractic manipulation sessions can sometimes cause swelling of tissues, delayed muscle spasm and a further visit to the chiropractor - a vicious cycle which serves to perpetuate further sessions. A prudent course following chiropractic treatment is to protect against further joint damage and embark on a program of exercise rather than additional chiropractic manipulations immediately. Manipulation of the neck or cervical region of the spine is extremely dangerous because the spinal cord lies within the spinal canal at that level of the spinal column. Manipulation of the lower lumbar region is less risky since the spinal cord ends just under the first lumbar vertebrae and is thus less likely to be damaged by manipulation. On balance, though, there may be benefits to specific manipulations especially when muscle spasm or facet joint movement is impaired. The American Medical Association recognized chiropractic practice in 1980 after many years of often heated debate about its validity. Current practice of chiropractic has also developed to include the study of kinesiology as proposed by George J. Goodheart in 1964. This branch of chiropractic practice proposes that it is possible to treat some disorders by locating muscular weakness and then manipulating the spine in a manner that directly stimulates and strengthens the muscle. A side effect of this development is the recognition that muscle weakness can be directly caused by allergy or nutritional deficiencies and is thus correctable in some cases by changes to diet. The discipline of chiropractic is served by the International Chiropractor's Association and the American Chiropractor's Association which promotes public education and provides continuing education and training to members. The most conservative course to consider if you are contemplating chiropractic treatments is to visit your physician or orthopedic surgeon and ask if muscle spasm or facet joint impairment is involved. If that is the case would he or she recommend a competent chiropractor or osteopath to solve that part of the backache? Mainstream medical professionals are now referring selected patients to chiropractors and osteopaths for some treatments and therapies, so manipulation is no longer the "dark science" it once was. In addition, many chiropractors are now recommending specific back exercises following manipulation which represents a "mainstreaming" of chiropractic practice towards recommendations and continuing care generally followed by physicians. Nevertheless, ask questions of professionals on both sides of the chiropractic issue regarding exactly what a manipulation treatment can and cannot do for you since there are limits to what chiropractic practice can achieve. Medications are available for some types of back pain, but be aware that there is no magic pill which will provide a quick cure. Generally three classes of medications are available to back pain sufferers: 1) pain relievers or analgesics, 2) muscle relaxants and 3) anti-inflammatory agents. Analgesics or pain relievers treat the symptom of a backache - the pain - but not the source. Tylenol and aspirin are the most commonly prescribed medications and aspirin has the added benefit of also being anti- inflammatory. However aspirin and tylenol may be only partially effective at relieving severe back pain. Stronger pain relievers such as percodan, vicodin or codeine- tylenol are usually prescribed for severe back pain. Codeine is, of course, addictive if taken over longer periods of time. For the most part these strong pain relievers are only offered during the first few days to a week of a painful episode and then discontinued. The strongest analgesics such as demerol and morphine are used on patients suffering from back pain in a hospital setting or after back surgery. They are obviously quite addictive. Recent studies of patients recovering from a variety of surgical procedures show that these patients tend to have a more rapid recovery when correctly treated with stronger pain relievers. Strong pain relievers such as morphine are dangerously addictive, but over very short periods can actually hasten recovery. If you are in severe or chronic back pain, do not be afraid to ask the doctor for a stronger pain medication if a low level analgesic is not controlling the pain - you may be able to recover more quickly and begin a suitable therapy or exercise program that much sooner. Strong or addictive pain medications are usually best discontinued within two or three days - a practice followed by most physicians. Appropriate bed rest is usually just as effective at controlling chronic pain as most analgesics after the first day or so. A different class of drugs, anti-inflammatory agents, reduce swelling in the muscles, ligaments and joints of the spine. The most effective are cortisone and related medications. Cortisone is not without side effects and is used very carefully by most physicians who watch and monitor a patient closely. Other anti- inflammatory agents include motrin, advil, nuprin, ibuprofen, indocin, naprosyn, clinoril, felene and voltaren. Side effects of these anti-inflammatory drugs include stomach irritation, nausea, diarrhea and vomiting. Not all patients will experience these side effects when taking an anti-inflammatory, but if you are taking one of these drugs, watch for side effects. Some patients will have inadequate anti- inflammatory effect with one drug and may need to switch to another medication under a doctor's supervision. This is common with anti-inflammatory drugs and a period of "testing" may be required by patient and doctor to find the one which gives best anti-inflammatory result with little or no side effects. Muscle relaxants loosen tight, spastic muscles. Robaxin, flexeril, and norflex are common drugs in this classification. Valium, a common but potent tranquilizer, is also a muscle relaxant but can be addictive over long periods of time. Most muscle relaxants work indirectly by affecting the central nervous system or brain and NOT by working directly on the muscle. In most cases these agents are useful during acute episodes of back pain - especially painful sciatic attacks which radiate down the legs. Some patients remain on these medications for several months, but in most cases the drugs are discontinued within a week or so after muscle spasm has decreased. Medications administered orally are but one route to managing back pain... Local injections are sometimes used to relieve back pain. The injected medications may consist of anesthetics alone or mixed with cortisone. In most cases these injections are done routinely in the doctor's office and provide only temporary relief. They may be helpful in allowing a patient to overcome the first day or two of pain after which adequate bed rest and therapy or exercise is usually prescribed. Epidural injections and facet joint injections are a variation of the above idea. These injections are given into a much deeper area - typically the irritated facet joint or exterior layer of dura of the spinal cord. Usually these deep injections are given by a licensed anesthesiologist under orders from a surgeon or physician. Unlike a superficial local injection, the deep epidural injection usually provides prompt relief for several days. A combination of cortisone and anesthetic is usually administered. Conditions such as disc ruptures, spinal stenosis or compressed or irritated nerve roots are comfortably treated in this manner. Relief does not last more than a few days and further injections or other therapies and specific back exercises are usually required in the end. Ultrasound heat treatments are usually given by physical therapists prior to additional massage or exercise of the back. Diathermy likewise projects heat deep into the tissues of the back and serves a similar purpose. By themselves, these treatments have little permanent value unless combined with additional exercises, massage or other therapies. Surgical procedures for treatment of back pain are the most drastic course of action. Frequently a physician will try other courses to remedy the pain since surgery is useful only in limited specific cases such as disc rupture. However, if a disc has failed, an orthopedic surgeon may attempt to remove its core via a variety of procedures. Percutaneous aspiration of a disc describes the removal of the pulpy core through a hollow needle which is inserted into the disc. A modification of this method adds a tiny spinning burr or reamer which is inserted through the needle and aids in breaking up the disc core. It is important to note that only the core is removed, not the entire disc structure. In most cases this surgery will relieve direct pressure of a ruptured disc upon adjacent nerve roots. However, the procedure has some risks such as possible disc fragments remaining near the spinal canal. Also, if back pain derives from nerve pressure due to overlying ligaments and muscles or narrowing of the bone through which nerve roots pass, this operation will have little beneficial effect. A surgical variation of disc removal is chemonucleosis which makes use of an injection of the chemical chymopapain into the core of the disc. This enzyme is derived from the papaya fruit and can selectively dissolve the tissue collagen which is contained within the disc core. Normally the needle is guided to the injection site by X ray image. Once the injection has been made, the core will slowly dissolve and in most cases relieve pressure on irritated nerves. Side effects to this procedure is the possibility of allergic reaction to the injection and the possible irritation of nerve roots if the chymopapain leaks out of the disc and comes into contact with nerve or muscle tissue. The procedure has limits in other ways: completely ruptured or extruded discs are not good candidates for this procedure. Likewise, elderly or arthritic patients are not usually recommended for chemonucleosis. The most aggressive surgical method for treating a herniated or ruptured disc is direct surgical dissection and removal of the affected disc core. In most cases back pain which focuses on irritated or compressed nerves may also derive from several sources in addition to the damaged disc. Removal of the disc core may thus be accompanied by surgical investigation of bony growths between vertebrae, stenosis or narrowing of bone canals through which nerves pass and compressed muscles and ligaments. Typically removal of the disc by direct surgical intervention is accomplished by direct incision over the affected spinal area. Overlying muscles and ligaments are retracted to reveal the disc space. The affected nerve root is usually revealed after additional bone is removed. Finally the nerve root is retracted and protected and the ruptured disc material is cut and suctioned from the site. Other bony spurs which have grown in proximity are trimmed with the idea of relieving pressure on the irritated nerve root. Bed rest and specific therapy exercises are usually prescribed depending on the recommendations of the surgeon. A different operation is attempted if a narrowing of spinal canal places pressure on nerve roots or the spinal cord itself. Sometimes this narrowing is a result of a disc rupture. Other times it is a matter of aging or other disease processes. This surgical procedure essentially opens a space around the nerve by removing some of the bony surrounding tissue which encases it. Foraminotomy is a similar processes but instead involves enlarging the smaller bony canals through which nerves pass - not the central spinal canal. Bony growths or spurs adjacent to the facets of the vertebrae may also be trimmed to reduce pressure on nerve roots during the surgery. Stenosis or narrowing of the spinal canal or smaller foramen through which nerves pass is more frequently seen in elderly patients over age 55. Spinal fusion is another surgical procedure which is sometimes attempted to relieve back pain. Sometimes damage or injury causes the movements of one intervertebral bone to become misaligned in relation to an adjacent bone or disc. The lower lumbar area is notorious for instability and vertebral injury. Back braces may be suggested to limit the range of motion in the lumbar area of the back and prevent pain. However an external brace may not be sufficient and a surgeon will attempt to permanently fuse two vertebral bones together by taking bone grafts from the large pelvic bone and bonding them to two adjacent vertebrae. Bone tends to mend and grow together if fractured or injured and this procedure makes good use of this biological predisposition by grafting bone together at the site of two adjacent vertebrae. Occasionally metal plates or screws are added if the area is unstable or needs extra support during healing. Surprisingly, patients who have undergone spinal fusion still retain a considerable range of motion in the back and over several months may not even be aware of any decrease in flexibility or function. Years ago surgical removal of a ruptured disc core was accompanied by spinal fusion under the theory that removal of the disc core necessitated spinal fusion to strengthen the underlying area. However, today disc removal is not usually accompanied by bone-to-bone intervertebral fusion since appropriate rehabilitation and back exercises can compensate to provide strength and support to the back. It should be noted that surgical fusion requires several months of recuperation for the grafted bones to heal and strengthen the site while disc removal causes only a few weeks of recuperation for most patients. The majority of patients who undergo surgery are pleased with the results. However a program of exercise, rest and specific medications are usually required - surgery is only a foundation for relief from pain. Many months may be required for complete recuperation and a return to a normal work schedule. Fundamentally, removal of a disc or spinal fusion is NOT the normal structure for a healthy back. In addition to exercises, proper techniques for sitting, standing and lifting will have to be learned by the recovering patient. This tutorial is merely a starting point! For further information on back care and back pain, be sure to register this software ($25.00) which brings by prompt postal delivery a printed, illustrated guide to back pain written by a physician plus two software disks. From the main menu select "Print Registration Form." Or from the DOS prompt type the command ORDER. Mail to Seattle Scientific Photography (Dept. BRN), PO Box 1506, Mercer Island, WA 98040. If you cannot print the order form, send $25.00 to the above address and a short letter requesting these materials. End of chapter. ---------- ABOUT THE AUTHOR - JIM HOOD PO BOX 1506, Mercer Island, WA 98040 (206) 236-0470 CIS: 72020,2176 ------------------------------------------------------------ I am commercial photographer by training and a computer hobbyist by preference. An odd combination of skills, but technology has always been a fascination. I live about 3 miles from Seattle, Washington on Mercer Island, a city of about 24,000 people in the middle of Lake Washington. As former coordinator for the Mercer Island Computer Club, I divide my time between computer related hobby activities and the operation of Seattle Scientific Photography which produces 35mm lecture/presentation slides for a variety of commercial clients. This disk, Back Relief Now, evolved as a project to learn about the source of my own back pain which is probably a consequence of long hours spent at a computer keyboard. The project also evolved from a feeling that common sense, a little medical research and exercise were probably the best course to follow. What unfolded was a surprising amount of information which could be shared with others who also suffer from backaches. The result is this software program which is written from a layman's point of view for the average layman to read. I attended the University of Sophia in Tokyo, Japan and Seattle University in Seattle. I have taught classes at the University of Washington Experimental College. Following are descriptions of other shareware packages I have published. Most are available from popular shareware sources such as computer clubs and shareware disk vendors, or you may contact me directly for further information at the address listed above.... PC-LEARN was selected a recommended beginner's choice by 21 computer clubs and has been featured in two national computer magazines. PC-Learn is a computer training system for beginners which includes chapters on buying and using a computer, an entertaining history of computers, DOS lessons, hard disk drives, tech tips how to use shareware tutorial and virus protection. It also includes information on word processing, a suggested reading list, software selection, mailing list of computer clubs, batch files, spreadsheets, databases, and even a glossary! PC-LEARN features high speed color or monochrome menus, tutorial printing, information searching capabilities and more. The SSP Directory of Computer Clubs. Every computer owner, from novice to advanced, can use this comprehensive directory of over 1,000 computer clubs and users groups to locate and benefit from the vast offerings which computer clubs and users groups offer. Edited by a former computer club coordinator, the SSP Directory of Computer Clubs is a comprehensive listing of major computer clubs and users groups which focus on the MSDOS and PCDOS family of personal computers. Includes a mailing list of computer clubs plus brief tutorial on the support services, newsletters, monthly meeting agenda and special interest groups of computer clubs. The mailing list and contact directory is provided in both plaintext ASCII which you can read and revise with your word processing software and also in dBase format so you can generate mailing labels or use your database program to effectively search and sort this large resource list. The SHAREWARE USER'S TUTORIAL is a detailed presentation on how to use and enjoy shareware! Topics include: eight easy steps to using shareware FAST, determining what is on a disk, how to run a program, how to unpack and unarchive, commonly asked questions, a short DOS review course, shortcuts, using filenames and extensions, locating documentation on disk. Even includes a short pop quiz to test your "shareware survival skills!" Chapter titles of this excellent tutorial are as follows: What is shareware, public domain, freeware and commercial software? Eight easy steps to using shareware FAST! Minimum DOS commands for using shareware. Copying the master disk. The directory listing of a shareware disk. File names and extensions - the keys to the kingdom. A turbocharged shortcut! Finding, reading and understanding documentation within a file. Unpacking and installing, including ARCS, ZIPS, LZH and more! Configuring the program if necessary. Running the program. Feedback: either register or send your regrets! Common questions and answers. Recommended reading list for shareware users and authors. Shareware vendors should consider adding this to their catalog as a reprint or at least sending this file with every order to customers! The $HAREWARE MARKETING $YSTEM received the Public Brand Software Trophy award in 1991 and 1992. It is a top seller at over 800 vendors. It is a quarterly updated marketing newsletter and complete mailing list of over 4,200 major shareware disk distributors, large computer clubs, key magazine editors, recommended BBS systems and more! Software programmers, disk vendors, agents and authors can use the detailed mailing list to mail software in an effective, highly successful manner. Also contains a massive marketing newsletter which has been prepared by an established shareware author and contains dozens of creative tips, tricks and traps every author and disk vendor should review. The database file mailing list is rated so you can mail shareware to key vendors ranked A, B or C. The database file is supplied in dBase III (DBF) file format. Program does NOT require color or special graphics. Requires database program such as PC-File, dBase or any database which can import dBase III format (DBF) files. Hard drive suggested. Single issue registration available as well as subscriptions - 4 quarterly issues per year. This tutorial is merely a starting point! For further information on back care and back pain, be sure to register this software ($25.00) which brings by prompt postal delivery a printed, illustrated guide to back pain written by a physician plus two software disks. From the main menu select "Print Registration Form." Or from the DOS prompt type the command ORDER. Mail to Seattle Scientific Photography (Dept. BRN), PO Box 1506, Mercer Island, WA 98040. If you cannot print the order form, send $25.00 to the above address and a short letter requesting these materials. End of chapter. ---------- ************** O R D E R F O R M **************** Make check payable to: SSP (Sorry, no VISA PO BOX 1506 (Dept BRN) or Mastercard MERCER ISLAND, WA 98040 credit cards) (206) 236-0470 CIS: 72020,2176 If your address and requested disk size DID NOT print correctly ABOVE (using the automated order program ORDER.EXE,) then print your corrected address in the space below: On the line below, who provided your copy of BACKACHE RELIEF NOW? ________________________________________________________________ BRN56 Your printed 22 page Back Care Guide and 2 software disks will be shipped promptly! qty ordered: ____ SINGLE ISSUE REGISTRATION $25.00 postpaid (Check in US funds) Valid for U.S.A. and Canada Washington residents add 8.2% sales tax ____ Foreign addresses add $5.00 shipping ---------- End of Document