INTRODUCTION

Back pain has been described as the "nemesis of medicine" and is the largest occupational health and safety problem in Australia, with an estimated annual cost of over $8b in disability and lost production (1). It has been estimated that 80% of the population experience back pain at some stage in their lives. However the number of injuries sustained and working days lost can be significantly reduced by adopting preventative occupational health and safety education programs (1-3). The following material is an educational page in spinal care to aid in the prevention and management of work place injuries.

1. Anatomy and function of the Spine

The spine is one of the most remarkable structures of the body (Fig 1) It has three fundamental biomechanical functions

  • To support weight of head and trunk onto pelvis
  • Provide sufficient mobility between head trunk and pelvis
  • Protect and enclose the spinal cord
These two opposing functions of stability and mobility is provided by the vertebrae which provide limited individual movements between vertebrae but extensive movements for the entire vertebral column. 
Fig 1 
Fig 2 

 

The vertebral column has three curves when viewed from the side. The vertebrae are separated by discs, which act as a shock absorber (Fig 2). They are composed a tough outer layer of ligaments (annulus fibrosis) which support the inner layer of gel-like fluid (nucleus pulposus).
The spinal cord is continuous with the brain and regulates the functions of every organ of the body. It provides impulses to and from every cell via the spinal nerves (Fig 3), which travel via the intervertebral foramina, bony openings between the vertebrae.

 

Fig 3

2. The Mechanisms of Spinal Pain

Spinal injuries are generally believed to be cause by a single incident or direct trauma, however the most frequent mechanism is a process of sustained and/or frequent loading and strain. Therefore back pain doesn't just happen rapidly - it develops. For example when an individual bends to pick up a box and develops back pain, he she tends to blame the box. In contrast, an individual who picks up a box and has a heart attack would not consider blaming the box for the heart problem The patient understands that, although the chest pain may have been triggered by a particular activity, the activity did not create the problem. It is important to understand that many back problems are similar to heart disease, they do not just happen.. .they develop. Therefore the cause of back pain is the result of an accumulation of stresses over a period of time.
Who is at risk? Everyone. But those who sit with poor posture, bend, or twist are at higher risk. Poor general health, lack of job satisfaction and loss of flexibility and trunk strength are additional factors.

3. Sources of Spinal Pain

Nearly all the structures of the back and neck can cause pain. Most commonly, muscles, tendon ligaments, or joints become sources of pain when overloaded. For example being on the telephone or working at the computer for long periods can strain the neck, upper back and shoulder. The joints and muscles of the back are able to cause local or referred pain (some distance from the origin).

 Fig 4
 The pain may be referred to the buttocks, legs, head, face or arms. The most notorious culprit of severe pain is the "herniated disc" (Fig 4).
If strained too much, especially movements involving bending and twisting (Fig 5) the disc can bulge or tear and allow the gel to move into the area of the spinal nerves causing sciatica/leg pain (Fig 6).  Fig 5
 Fig 6
 An interesting point is the disc bulges occur in one third of all people who have no symptoms at all; thus such a finding in a patient may be coincidental.

4. Mechanical Strains of Daily Activities

Normal upright spinal posture reduces potential strain. Unfortunately our modem sedentary lifestyles by overusing the sitting position in cars, watching TV and working at desks and computer stations have imbalance our normal upright posture (Fig 7). Humans were not designed to SIT.

 

Fig 7. Effects of posture on lumbar disk pressure

 The signs of poor posture include the following:
  • Weight over the balls of our feet
  • Sway back
  • Increased roundness of mid-upper back
  • Rounded forward shoulders
  • Forward head with chin poked
To correct poor posture it is helpful to attempt the 'military position' (Fig 8) which involves:
  • Flattening your low back against a chair or wall
  • Rolling your shoulders back and down
  • Tucking your chin in while you glide your head back
 Fig 8

5. First Aid for an Acute Episode of Back Pain

Acute disabling episode of back pain can provoke anxiety and anger. Until your back 'goes out' you do not realize just how many activities place strain on your back. Fortunately, such episodes typically are transient and calm down after 2 to 3 days. However approximately 5-15% of all individuals suffering a back problem will develop chronic back pain. Therefore much can and should be done to ensure that an acute episode does not mushroom into severe chronic episode. Following are steps to aid in acute back pain:

  • Reduce external strain and maintain positions of relief; lying on back in 90/90 position (Fig 18)
  • Apply ICE for 15 mins on/off for 4-5 times per day; avoid heat in the first 2-3 days
  • Avoid sitting for long periods, keep walking between periods of rest
  • Avoid twisting and bending; when rising in the morning get up on your side (Fig 19), and keep your trunk rigid as you turn your whole body in and out of the car
  • Move to the edge and use the arm rests when rising out of a chair

Consult your chiropractor on gentle treatments that speed the initial goal of stabilizing the painful area and avoid re-injury. As soon as your acute pain begins to ease, the second goal of care is to get you active by relaxing muscle tension and loosening stiff joints. The third and final goal is to achieve reconditioning of your "weak link". This weakness is targeted with stretching and strengthening exercises and unless addressed will predispose you to future recurrences

6. The Role of Chiropractic

Back and neck pains are interwoven into our lives. They are common yet unpleasant experiences that, if mismanaged can become chronically disabling (15%),(2). According to recent independent government studies from Canada, the United States and Britain concerning the back pain problem, consensus has emerged that this poor report card is related to the overprescription of bed rest and medication and the failure to restore functional integrity to joints and muscles.

What is the Solution?

The Rand corporation, British Low Back Pain Guidelines, and the U.S. Agency for health Care Policy and Research have found that chiropractic management and spinal manipulation is one of the most effective forms of early intervention for back pain (4-7). The Manga (5) report found "On the evidence particularly the most scientifically valid studies, spinal manipulation applied by chiropractors is shown to be more cost effective than alternative treatments for low back pain". The authors also concluded that chiropractic manipulation is safer than medical management of low back pain (5). Another study showed that the average chiropractic bill for work related back injuries was less than half that of medical treatment (9).
Manipulation in combination with rehabilitative exercise and simple education has proven to be far superior to traditional prescriptions of prolonged bed rest and medication.

Sitting

The sitting posture causes fatigue because it creates pressure on the discs of the low back and the muscular effort required keeping both our neck and back upright (Fig 9a). The correct sitting position (Fig 9b), involves:
Low back well supported ~ Seat back slightly reclined
Seat at height such that your hips are level or slightly higher than knees
Feet rest comfortably on the floor. Use arm rests if available. When working at a desk or computer the following ergonomic checklist I follows:

Chair

  • Seat height adjustable
  • Feet should be on the floor and knees no higher than hips
  • Good low back support
  • Seat back should be able to recline (95 to 1050)
  • Tiltable seat pan; fwd for work at desk/bwd for reclining work
  • Center of monitor at nose level and no glare on monitor
  • Keyboard height so that wrists are not bent, elbows at 900 and shoulders
    relaxed (not shrugged)
  • Have the use of a document stand

 

 
 Fig 9a. Improper sitting postureFig 9b. Proper sitting position for reducing finger, wrist, elbow, shoulder, neck and back strain

The slumped head-forward posture causes the muscles of the neck and shoulders to become fatigued and strained (Fig lOa + b). Headaches, neck, shoulder and arm pain can result from this posture therefore it is important that your shoulders are relaxed back and down when you sit or stand. A simple exercise of rolling your shoulders back and down (by squeezing your shoulder blades together) rotate your hands out and tuck your chin (Fig 11), performed frequently throughout the day can prevent these ill effects of the slumped posture.

Fig lOa. Proper head/neck posture

Fig lOb. Slumping posture and the dowager's hump

  
Fig 10. Postural exercises for rounded shoulders and forward head posture  

 

Sleeping

Your posture for sleeping is also important. The ideal sleep posture includes:

  • Maintenance of normal spinal curves, that is either on your back or side, not on your stomach.
  • Avoid lumbar spine and pelvis twisting; use a pillow between the knees
  • When sleeping on our back, pillow under knees will allow back to relax and not overarch
  • Pillow which cradles and supports the neck without distorting its normal alignment (Fig 12)

If your pillow is not supporting you properly, too big or too small, you might wind up with recurrent 'stiff necks', headaches, or even referred pain to the shoulder or arm. Remember that your head is bigger than you neck, so accommodating both without distorting the position of your neck may require a special orthopedic pillow.

 

 Fig 12.

A. Healthy neck/pillow relationship
B. Too small of a pillow
C. Too large of a pillow

Lifting

Lifting is properly the area of greatest concern in relation to work place injuries. The proper lifting technique (Fig 13) follows:

  • Avoid lifting after a period of rest
  • Always test the weight of the object
  • Lift with your back straight
  • Never bend and twist while lifting
  • Keep the object as close to your chest as possible
  • Keep things that need to be moved at waist level
  Fig 13. Proper lifting technique from the ground
 Fig 14  Lifting children can be especially difficult, as they don't sit still like boxes do. Avoid carrying a baby with outstretched arms by holding the baby close to your chest you greatly reduce the potential strain. This advice is particularly important when putting a baby in a car seat
 Fig 15 Changing your baby is another opportunity for back strain. The rule is have the changing station of appropriate height to avoid bending forward (Fig 15).
  A footstool can be used in the situation to reduce back strain along with other daily activities such as ironing, cutting vegetable, folding laundry or brushing teeth (Fig 16 and Fig 17).

Fig 18 - Back relief in the 90/90

 

Fig 19. Technique for getting out or in bed with bad back