Treatments

Introduction

Back pain is very common.  Globally, the point prevalence of low back pain is estimated as 7.5%.  Female has a higher prevalence than male.  Low back pain is the leading cause of years lived with disability (YLDs).  YLDs peaks at 45-49 years of age, again higher in females than males.  Low back pain is the second most prevalent illness caused by work and the commonest illness made worse by work.  According to the Bureau of Labour Statistics of USA, back injuries account for one of every five injuries and illness in workplace.  Eighty percent of these injuries occur to the low back and are associated with manual material handing tasks.

Local data from a cross sectional survey revealed that 21% of adults had LPB in the past year.  Another survey on self-reported work-related illness found 42.1% population suffered from LBP at least once within the past year. 

Stay Physically Active

A sedentary lifestyle is an important risk factor for low back pain in adults and children. Adults sit and drive for a long time; children spend long periods of time watching TV, using computers/mobile phones and playing video games, with little or no exercise/physical activity, are all sedentary lifestyles. Excluding sleep time, about one-fifth of Hong Kong people aged 15 or above sit or stay in bed for more than 10 hours a day. Sitting for long periods of time reduces posture changes, reduces muscle strength, contributes to disc degeneration and low back pain.

For adults 18 years of age or older, the World Health Organization recommends at least 150 to 300 minutes of moderate-intensity aerobic/aerobic exercise, or at least 75 to -150 minutes of vigorous-intensity aerobic exercise per week. More than half of the local population is inactive/physically active. A physically active lifestyle is a good start in preventing back pain.  Physical activity is the combined result of exercise intensity, duration, and frequency. That is, less-intensive exercise performed over a longer period of time has the same positive impact on health as more-intensity exercise performed over a shorter period of time. Exercise that makes your heart beat faster and stronger, and feels sweaty or heavy breathing is considered moderate-intensity exercise. In addition to cardio exercises such as brisk walking, running, cycling, or swimming, abdominal crunch exercises and other core exercises can help support your spine and help prevent back pain.

Body Weight Control

Being overweight or obese is strongly associated with low back pain in adults and children. About 20% of Hong Kong students are overweight or obese. Overweight and obese young people are likely to remain obese into adulthood. According to the 2014/15 Hong Kong Population Health Survey, about 30% of adults are obese and 20% are overweight. Body Mass Index (BMI) is the weight in kilograms divided by the square of the height in meters. For Asians, a BMI ≥ 23 indicates overweight; a BMI ≥ 25 indicates obesity. In addition, according to waist circumference, about 30% of the population has central obesity (waist circumference ≥ 90 cm in men or ≥ 80 cm in women). Being overweight can overload the spine and lead to disc degeneration and low back pain. A healthy lifestyle, regular exercise and a proper diet are the pillars of weight control. To burn fat or belly fat, it is best to do moderate aerobic exercise for ≥ 30 minutes on a regular basis, such as jogging, brisk walking, swimming, cycling, fast-paced social dancing. These must be combined with foods that are low in sugar, low in salt, low in fat and high in fiber.

Do not Smoke

Smoking is strongly associated with back pain. The more you smoke, the greater your risk of back pain and leg pain. Teen smokers are 2.4 times more likely to have back pain than non-smokers. Compared with non-smokers, men who smoke are 18% more likely to have low back pain, 25% more likely to have disc degeneration, 33% more likely to have spinal instability, and 49% more likely to have spondylolisthesis, and 52% more likely to have spinal stenosis.  Women who smoke are 50% more likely to suffer from chronic back pain than women who never smoke. Compared with non-smokers, smokers had less improvement in symptoms after lumbar disc herniation or lumbar spinal stenosis surgery, and higher rates of surgical site infection, wound complications, and nonunion after spinal fusion.

Smoking increases blood pressure and heart rate; reduces blood flow to the heart and the amount of oxygen delivered to body tissues; increases the risk of blood clots and blood vessel damage. Smoking increases the risk of heart disease, stroke, heart failure and atherosclerosis. In addition to reducing blood flow to the spine and nutrition to the discs, smoking can lead to vitamin D deficiency and osteoporosis. A sedentary lifestyle and smoking are both risk factors for osteoporosis and vertebral compression fractures.

Back pain and associated leg pain are less common in former smokers than in current smokers, so quitting smoking can relieve back pain and may also improve outcomes after back surgery.

Proper Posture

Maintain good posture and pay attention to body posture while working. Work comfortably, changing body position frequently.

By maintaining a neutral posture, the body will find its natural balance. When standing, keep the spine aligned on its natural curve (cervical lordosis, thoracic kyphosis, and lumbar lordosis). When sitting, keep your head naturally balanced on your shoulders (not protruding in front of your body) and keep your shoulders relaxed (not hunched or sagging). Sit back in the chair for support (don't sit on the front edge of the chair) and adjust the back so that it remains in a normal, slightly arched position. Keep your thighs and forearms parallel to the ground. The wrist should be straight, not bent or twisted. Don't sit in a slouchy, sagging posture at your desk.

Static postures can cause discomfort and reduce productivity. If you're working at a desk or in a static position, it's a good idea to get up at least once an hour, stretch your back and leg muscles, and walk around to give your back a break. Avoid sitting with your legs crossed, which puts the spine in a side bending position and puts an asymmetrical load on the back.

Position the computer display screen slightly below eye level, with a viewing angle of about 15 degrees. The top of the screen should not be at a level higher than the eye level.  Looking up (above the horizontal) can be tiring. It is helpful to have a document holder in front of or on the side of the display screen. If your computer is a laptop, use a separate keyboard and external mouse. The mouse and keyboard should be at elbow height. Bring your arms and elbows close to your body, and your wrists should be straight. Sit back and lean back slightly in the floor. The knee angle should be greater than 90 degrees, with the thigh parallel to the ground. Put your feet on the floor or on a footrest. Take breaks every 20 minutes for 20 seconds and look at least 20 feet away from the display screen ("the 20/20/20 rule").

Proper Lifting

Before lifting heavy objects, take some time to determine a plan for lifting and carrying heavy objects. Estimate the weight of an object and know your own limits. At age 65, muscle strength is 75% of that at age 20 to 25. The average lifting capacity of women is about 60% of that of men. Avoid lifting more than one-third to one-half of your body weight. If you have to hold your breath to lift it, it is too heavy. If the item is too heavy or in a difficult shape to handle, seek help from others.

When lifting heavy objects, stand near the object with your feet shoulder-width apart and a wide stance for solid support. Make sure to hold the object well. The safe lifting zone is located between the knees and the shoulders. If the object is lower than your knees, bend your knees, tighten your abdominal muscles, and lift with your leg muscles as you stand up. Keep your elbows by your side as you lift the object. Lift smoothly without jerking. Avoid twisting your waist and side bending when lifting weights. As you hold the object, keep your knees slightly bent for balance, keep the object close to your body, don't lean forward, and don't fully extend your arms. If the item is above your shoulders, use a stool or ladder. It's best to store heavier, frequently needed items on the middle shelf of a closet or cupboard for easy access.

To move heavy objects, consider sliding instead of lifting and moving. Pushing a heavy object is easier than pulling a heavy object, and pulling a heavy object is easier than moving a heavy object. Before moving objects, take care to keep aisles clear. If you must move the object to one side, point your feet in that direction and move your body in that direction. Avoid putting your feet on the floor and twisting your torso. If you must place objects on a shelf, get close to the shelf with your feet apart and one foot forward for solid support.

To pick up a small and light object from the floor, the golfer's lift technique is especially useful. The knee is slightly bent on the supporting leg. Tighten your abdominal muscles and keep your back straight. Lean on a solid structure, or place one hand on your knee for support. Using the hip joint as a fulcrum, lean forward by bending the hip so that the body is parallel to the ground and gently extending the other leg behind you for balance. Then reach to pick up the object and lift slowly and steadily, straightening your hips to lift the object. This technique is considered safe for the lower back, as lifting one leg toward the back keeps the spine straight and counteracts the strain on the back. The golfer's lift is especially useful for repeatedly lifting small objects.

Prevention of Back Pain after Delivery

During pregnancy, ligaments naturally become soft and elastic in preparation for labor. This can strain the joints in the lower back and pelvis, which can lead to back pain.

Caring for a baby and breastfeeding can be a daunting task for parents. Repeat lifting the baby from the crib or floor and placing the baby in a high chair, stroller, or car seat 50 times a day. The average birth weight of Hong Kong babies is 3.1kg. As the baby grows, its weight increases. The average weight is 7.5 kg at 6 months, 9 kg at 1 year, and 11 to 12 kg at 2 years. Avoid leaning over and holding this position for long periods of time. Frequent lifting of an infant and the actual weight load, or incorrect lifting can all lead to back injuries.

The principles of proper lifting apply to lifting and holding babies. To pick up the baby from the crib, spread your feet apart and pull the baby towards you. Then bend your knees, contract your abdominal muscles and lift the baby to your chest. To lift the baby off the floor, bend your knees (not your waist). Squat down and tighten your abdominal muscles, hold your baby to your chest and straighten your legs to pick up your baby before lifting. Likewise, use a squat position to get the baby in and out of the stroller. Remove the high chair tray before placing the baby in the high chair or taking the baby out of the high chair.

When walking with a baby, a front baby carrier is more suitable for back health than a rear carrier. Infant car seats are heavy. Consider securing the car seat in the car first and then bringing the baby to the seat. The safest place for a stroller seat is in the middle of the back seat. Avoid standing outside the car when placing the baby in the car seat. You can sit next to a car seat with your baby on your lap, then turn your entire torso to one side and place your baby in the seat.

When breastfeeding, mothers should sit or lie down in a comfortable, relaxed position with good back support. When breastfeeding in a seated position, the mother should support the baby on her lap with a pillow and hold the baby high enough so that she does not have to lean forward to place the baby onto the breast. Hold your baby close to your body up to the breast; don't bend over to feed your baby. The baby's head and body should be in a straight line. The baby's face should be opposite the nipple. For new born, support the baby's head, shoulders, and hips. The main support is the pillow. It is best to sit in an upright chair rather than a soft sofa. Put your feet on the stool to prevent your body from leaning forward and avoid back pain.

Breastfeeding in lying on the side is a good option, especially if you have a caesarean section, a difficult delivery, or breastfeeding in the middle of the night. The mother lies on her side with her head on a pillow, arms bent and knees bent to relax her lower back. Place the baby on one side with the mother and baby facing each other, with the head facing the breast and the body touching the mother's chest and abdomen. Put the lying arm under your head or pillow (make sure your baby's position is not changed by the pillow), and use the other free arm to support and guide your baby's head to the breast.

Prevention of Back Pain in School Children

Obesity and sedentary lifestyle are risk factors for nonspecific back pain in schoolchildren. Another risk factor is an overweight school bag. Back, neck, and shoulder pain can result from packs that are too heavy or don't fit properly. Heavy backpacks do not cause scoliosis.

Choose a lightweight backpack with wide, well-padded shoulder straps and waist strap to distribute the weight of the backpack across the back.  Always use both shoulder straps, tighten the shoulder straps and waist strap to keep the backpack closer to the back. Organize the contents so that the heavier books are placed low, towards the canter of the pack. When lifting the pack, bend your knees and lift properly. The recommended backpack weight is less than 15% of the schoolchild's body weight. Heavier loads increase the risk of musculoskeletal injury. Observe whether the child struggles during the process of putting on and taking off the backpack. If your backpack is too heavy, consider bringing only what you need for the day. Make good use of school lockers and consider purchasing a second set of textbooks to keep at school.

Prevention of Back Pain in Elderly

Degenerative lumbar disc disease and lumbar spinal stenosis are common causes of low back pain in older adults. Another common cause is osteoporotic vertebral compression fractures. Women over the age of 50 have a 40% lifetime risk of developing a spinal vertebral compression fracture. As many as two-thirds to three-quarters of vertebral compression fractures are asymptomatic and have no back pain. However, one in five postmenopausal women with an incidental finding of a vertebral compression fracture develops a subsequent vertebral compression fracture within 12 months.  Vertebral compression fracture is associated with significant pain, disability and impact to the quality of life and physical health. 

Most vertebral compression fractures in older adults are osteoporosis-related fragility fractures that fall at standing height without even a clear history of injury. Many factors that contribute to osteoporosis are modifiable, such as physical inactivity, insufficient calcium intake, vitamin D deficiency, smoking, excessive alcohol intake, and use of medications such as steroids. Falls are preventable. Osteoporosis is amendable with medication.

Spine Conditioning after Back Injury or Back Pain

After a back injury, back surgery, or back pain episode, it is important to restore back mobility, strength, and spinal health. Pain is not necessarily a contraindication to spinal conditioning exercises. Spinal conditioning exercises can be performed in a controlled, progressive manner under the supervision of a physician and physiotherapist, with pain reduction and management as part of the exercise program.

A spinal conditioning exercise program includes exercises to aid the recovery process, with an emphasis on flexibility, strength (general body and target muscle areas), and bodily function. An effective spinal conditioning program should be comprehensive, including the entire body, even if it targets the back. Balanced rehabilitation should include a combination of muscle stretching and strengthening exercises, as well as low-impact aerobic exercise. Start with a warm-up with 5 to 10 minutes of low impact activity, such as walking or riding a stationary bike. After your warm-up, do the stretching exercises before moving on to the strengthening exercises. After completing the strengthening exercise, repeat the stretching exercise to end the training.

Regular stretching of the muscles, tendons, and ligaments that support the spine is an important part of any back exercise program. Stretching reduces the tension in the spinal muscles; tight muscles can worsen back pain. Stretching improves range of motion and overall flexibility. It reduces the risk of disability from back pain. It is recommended to do stretching exercises at home every day. Chronic back pain may require months of regular stretching for successful pain relief. Stretching should be done slowly to avoid bouncing. Hold the stretch long enough (15 to 30 seconds) and repeat several times.

Back stretches include back and hip flexion/extension stretches, rotational stretches and side seat stretches.  Some examples of back stretches are back flexion stretch, kneeling back extension, knee to chest stretch, piriformis stretch, kneeling lunge stretch and hamstring stretch.  Do not forget the hamstring muscles; tight hamstring muscles is a common contributor to lower back pain.  With age, the spine becomes stiff and prone to injury. Rotation and side-seat stretches promote spinal mobility, a key factor in maintaining spinal health. 

Back strengthening exercises aims to tone the muscles to better support the spine, withstand stress, and relieve pressure from the discs and facet joints. Exercise can relieve stiffness and improve spinal flexibility. Improved blood circulation helps better distribute nutrients to the spine, including the intervertebral discs. Exercise releases endorphins, which naturally relieve pain and help reduce dependence on painkillers. Exercise can elevate mood and relieve depressive symptoms common in chronic pain. In the long run, exercise can reduce the frequency and severity of back pain attacks.

With the exception of the muscles around the spine, especially the erector spinae and multifidus, most back strengthening exercises focus on the core muscles. The core muscles surround the centre of the body and are responsible for protecting the spine. The position of the core muscle group is about the structure of the human body from below the diaphragm, around the waist and abdomen, the centre of the trunk to the pelvic floor. It consists of muscles in different parts of the deep and superficial layers, such as abdominal muscles and back muscles, gluteal muscles, and thigh muscles. Core strengthening exercises train the muscles of the pelvis, lower back, hips and abdomen to work in concert. This allows for better balance and stability in daily life and physical activity.

Another important component is low-impact aerobic exercises without jarring the spine and exacerbate back pain. Some popular low-impact aerobic exercises include brisk walking, cycling, swimming, and water aerobics, as well as the elliptical walker or stepper.

Summary

A sedentary lifestyle, obesity, and smoking are well-known risk factors for low back pain. Moderate physical activity, a healthy weight, and avoiding smoking can protect your back. Proper posture and proper lifting during daily activities or work can help prevent back injury or pain. Pay attention to the problems and effects of new mothers carrying babies, breastfeeding, school students' backpack load and osteoporosis and falls in the elderly. Spinal conditioning is very important after a back injury, back surgery or back pain attack. Stretching exercises, back and core strengthening exercises, and low-impact aerobic exercises restore back mobility, strength, and spinal health.

Dr Ho Sheung Tung