Lockdown and Low back pain

Keep Learning and Exploring more➡️ https://otpthealthcarerehab.blogspot.com

Today, due to Corona virus pandemic the whole world is under lockdown. This has lead to altered daily routine of many people. Most of the employees doing 'work from home' are spending their time by sitting in front of computer screens, television and mobiles. On the other hand, lockdown has lead to increased workload of homemaker because of increased physical activity for completing household chores. This sudden change in working routine and patterns have lead to complaints of low back pain (LBP) in many people. Sedentary lifestyle as well all excessive work beyond limits contributes in developing back pain.

Common sites of lumbar strain is along the iliac crest. Here, many forces converge around the attachment of lateral raphe of the lumbodorsal fascia like quadratus lumborum, erector spinae and iliolumbar ligament. Injury to this region frequently occurs with falls and with repeated loading of the region during lifting or twisting motion. 

     In last blog on 'Low back pain and supporting structures of Spine' we have learned about what is LBP, its causes and supporting structures of spine. 

https://otpthealthcarerehab.blogspot.com/2020/06/low-back-pain-and-supporting-structures.html

In this article we will learn about the factors that can be associated with LBP :

 1) Muscle Endurance : Poor muscle endurance in back extensors muscles has greater association with LBP. Strength is critical for controlling large load or responding to unpredicted loads. If passive or inert supports are impaired then dynamic supporting structure namely global and deep muscles has to compensate and vice versa. This will lead to extra burden on the working or functioning spine structures thus can lead to lumbar injury, sprain or strain. For example, in degenerative disc or ligamentous injury the dynamic supporters has to work more and increased amount of efforts are required to maintain or balance the posture. 

• Intervention : 

1. Increase mobility in restricting muscles, joint, fascia. Manual stretching and joint mobilization; teach self-stretching.
2. Develop neuromuscular control, strength and endurance in posture and extremity muscles. Stabilization exercises; progress repetitions and challenge with extremity motions; progress to dynamic trunk strengthening exercises.
3. Identify safe aerobic activities. Implement and progress an aerobic exercise program. 
   

2) Type of fibers : Muscle fiber composition may give some indication of functional capacity of these back muscles. Greater percentage of type I fibers (for aerobic and longer duration work) than type II fibers (for quick, powerful, more intensity work) are found in all back muscles. This is reflective of their postural and stabilization function. Inactivity can lead to changes in muscle fiber composition thus leading to decreased muscle endurance and further leading to early tiredness and experience of back pain during sustained or repetitive activities.

Intervention : Promote healthy exercise habits for self-maintenance. Integration of a fitness program, regular exercise. 

Fig : Aerobic exercises

3)  Postural alignment : Correct postural alignment is required to perform any activity. Poor posture significantly increases the effective load (weight) to the spinal joints and triggers counterbalancing muscle contraction (effort). Always remember try to maintain your spine in neutral as much as possible while performing any activity. Try to relieve extra pressure off spine by making efficient use of upper and lower limbs strength, adopting ergonomically correct postures, environment modifications. For example; 

• During activities like lifting weight from floor bend from hip and knee more instead of waist.

• While doing kitchen activities like making food, cutting vegetables etc the worktop height should be sufficient enough to avoid extra cervical flexion and bending from spine that would lead to stretch weakness and pain of back muscles.

• While doing fine, precision work activities like jewellery making, stitching clothes, making embroidery on clothes, diamond cutting, small wood carving etc the platform height should be about 5 cm above elbow height (elbow support is needed)

• When cleaning or sweeping floor make use of long handle rotatable brooms. This will prevent us from excess bending from spine, prevent excess kneeling and hip flexion while cleaning floor under table or sofa.
  

To maintain upright posture little muscle activity is required. But with total relaxation of muscles, the spinal curves are exaggerated and passive structural support is called on to maintain posture. Common faulty postures are lordotic posture, slouched posture, flat low-back posture, flat upper-back and flexed cervical spine. These adaptation of faulty postures can lead to imbalances in agonist and antagonist trunk muscles thus can further lead to stretch weakness or tight weakness.

Fig: Faulty spine postures

Fig: Correct (Neutral) spine postures in various activities (green colour) 

Fig : Foot rest or small heighted stool while doing table-top activities in standing to relieve burden from spine extensor muscles.

Fig : Office syndrome : musculoskeletal problems

• Intervention :

1. Educate the patient about the relationship between faulty posture and symptoms. Practice positions and movements to experience control of symptoms with various postures. Avoid keeping the spinal postures in same position for longer duration. Avoid adopting or maintaining any awkward posture for doing any activity. Periodically make changes in posture to relax the contracted muscles. 
2. It may be necessary to use a lumbar pillow for support during prolonged sitting or to modify the work environment (work station) to relieve sustained stressful postures.
3. Stress management or relaxation: relaxation exercises and postural stress relief.
4. Develop awareness and control of spine postures : Kinesthetic training; cervical and scapular motion, pelvic tilts, control of neutral spine. Utilize and practice procedures to develop and reinforce control of posture when sitting, standing, walking, and performing targeted functional activities. 
5. Integrate a progression of postural control into all stabilization exercises, aerobic conditioning, and functional activities. Patient is observed, reminders are provided to find neutral spinal position and initiate contractions of the stabilizing muscle prior to the activity. For example, when reaching overhead, the patient learns to contract abdominal muscles to maintain neutral spine position and not allow the spine to extend into painful or unstable range. This is incorporated into body mechanics, such as when going from picking up and lifting to placing an object on a high shelf, or into sports activities when reaching up to block or throw a ball. 

Fig : Body posture and alignment while doing work from home (laptop or computer work)

Fig: Angled table-stand for laptop work or reading activity relieves the pressure off neck and maintain neck in neutral i.e. excessive neck flexion or forward head position is avoided

Fig : Easy and simple office execises. Relaxation and stretching should be performed after every 1 hour of work. 

Fig : Neck and trunk muscles simple range of motion exercises and stretching. Neck muscle stretching should be performed after every 30 minutes or 1 hour. Avoid maintaining same static neck posture for longer hours.

4) Working Techniques : should be kept in mind while doing any manual physical activity. Consideration of body lever system and torque (leverage) is important while working especially while doing heavy gross-motor activity. Lever helps us do work more efficiently. They help us lift more or move faster. Muscles and bones act together to form levers. The lever system consist of 

• Lever arm (Bones) / Effort arm
• Joints act as fulcrum
• Muscles provides the effort forces to move load
• Weight of body part or force needed to lift, push and pull things acts as load

There are 3 types of levers. In human body, the 3rd class lever is most common. Here, the force is applied between the load and joint. This means that with regard to force and efforts, our anatomical levers are naturally structured to be inefficient. There is no mechanical advantage because effort needed is greater than load. However, this disadvantage is compensated with larger movement achieved and gives us much greater speed of movements.

Fig: 3 types of lever system in human body 

 

Fig: Back is a 1st class lever

To reduce the effort of spinal musculature, while lifting or holding, the load should be close to body i.e. reduce the load arm. No single vertebra joint could provide the amazing flexibility and maintain the stability that is required of the back. Therefore, each disc between the vertebrae provides a small amount of motion. The sum of this motion gives the back the needed flexibility. If this flexibility is abused through high force and/or repetition, the chance of injury is increased.

Torque : It is the ability of a force to cause rotation on a lever. It is a force applied over a distance (lever arm) that causes rotation about a fulcrum (joint axis). Torque depends on 3 variables :

• amount of force (muscular) (MF)
  
• angle of application of force (a)
• length of moment arm (IMA) 

Fig : Torque forces at various angles of elbow joint 

 

Fig: Torque forces on spine and it relation to moment arm

In the above picture, the person on the left side is bending from spine (thoracic joints) and the lifting force is at a greater perpendicular distance to the pivot (vertebral joint). In this position, the back muscles must exert a huge force to provide a torque that balances the torque from the weight being lifted. If the spinal structure of the back is weak then this will lead to muscle strain or ligament sprain. Majority of injury occurs due to overloading and incorrect execution of movement. Therefore, it is important to keep load close to body (decreased perpendicular distance to pivot) while lifting  as well as doing some amount of squatting (using hip and knee musculature) as performed by the man in right side.

• Intervention: 

1. Teach safe body mechanics. Functional exercises to prepare for safe mechanics (squatting, lunges, reaching, pushing/pulling, lifting and turning loads with stable spine)
2. Learning and implementing use of energy conservation and joint protection techniques.

• Respect For Pain : Stop activities before you reach the point of discomfort or pain. Limit activities which cause your pain to last more than one hour after you have stopped the activity. 
• Balance Activity And Rest: Rest before becoming tired. Plan rest periods during longer or more difficult activities. By resting 10 minutes during an activity, you will have more energy to continue. 
• Avoid Activities Which Cannot Be Stopped : When you begin to feel joint pain, stop. This will eliminate excessive pain and fatigue later. Prioritize activities. Consider the activity, length of time, and difficulty before beginning. Plan difficult activities for “peak” energy times.
• Use Larger, Stronger Joints For Activities, When Possible, Distributing The Weight Over Non-involved Or Stronger Joints : To lift a bag from a counter, bend your knees, hug the bag with both arms. Bend your elbows so that the bag is held tightly to your chest and   straighten your knees. Keep hold on the bag by keeping your elbows bent. If the load is too   heavy, push shopping cart, or get help with  groceries - use drive-up service. 

• Avoid Staying In One Position For Extended Periods Of Time : Plan rest periods. Change your position. Stretch and relax your joints. 
• Maintain Or Use Your Joints In Good Alignment : Maintain proper posture. 
• Maintain Proper Weight : Additional weight can stress weight-bearing joints (hip, knees, feet, back). Before lifting any heavy object initially anticipate or check for the weight.      

5)  Obesity or overweight : Excess body weight puts extra stress on your back and this pressure is also transmitted to the intervertebral disc. Different body positions has different pressure gradient on intervertebral disc. Injury or degeneration of the disc affects spinal mechanics. Excess weight in the belly area can cause your pelvis to pull forward (anterior pelvic tilt). This is a condition known as lordosis. As the curve in your back gradually becomes more pronounced due to lordosis, your back muscles tighten under the pressure contributing to chronic strain and pain.

• Discal pressure changes in different body positions : The highest discal pressure are seen in loaded slumped sitting, that is sitting with the lumbar lordosis reversed (flexed) while holding a weighted object. The lowest discal pressure is when we supine. Thus, people should be made aware of these pressure gradients with respect to body position so that excess loading of the spine, while doing any heavy activity, is avoided in particular position. This can lead to chances of prolapsed disc and increased stress on  other spinal structures  especially in people with medium, heavy and very heavy work level job,  in middle to late adulthood and geriatric people, and in housewives.
  

• By early adulthood, biochemical changes occurs that cause everyone's discs to start drying out. The disc lose volume and there is decline in water-retaining capacity. Owing to fatigue loading and disproportionately high pressure over time the disc (annulus) becomes less able to withstand increased pressures and thus in future can lead to nuclear material to bulge, protrude or herniate out when loaded. This can lead to prolapsed intervertebral disc (PIVD). Symptoms of pain arises, neurological signs arise from pressure against the spinal cord or nerve roots. 

Fig : PIVD

Intervention : 

• Obesity is a strong predictor of adult morbidity and mortality. Any loss of weight is beneficial in reducing many of the complications. Physical activity is important for maintaining long-term weight loss and co-morbidities. Combination of aerobic interval training and high intensity anaerobic interval training (HIIT) exercises is beneficial. For every 4 pounds (1.8 kg) of weight you lose, you remove 16 pounds (7.26 kg) of additional pressure placed on your spine.
• Adopting healthy lifestyle modification : daily 45 minutes to 1 hour of exercises for 5 days a week, follow low carbohydrate diet (emphasize on foods high in proteins and fat), stress management.

Thankyou for reading!!!

( Dr.Ashwini Sangar, Dr. Sheetal Tatar-Dhande, Dr. Pallavi Khadse-Kolhe)