Computing from bed: laptop stands

Modern life includes a lot of computer use, which for most people means sitting down. Back pain can make sitting prohibitively painful. Laying down is often more comfortable. One option is to lay on your stomach, propped up on your elbows, with your computer in front of you. This is a cheap and easy way to save your back. For some people (myself included) however, this kind of constant extension quickly becomes painful. Even if it doesn't hurt now, given the extensive stress this can cause to your spine it would be wise to get up and move at least once an hour if you use this pose.

The other option is to lay on your back, with your legs propped up and your laptop balanced against your thighs. While putting little stress on your back, this can be hard on your wrists and your neck. To make this more ergonomic you need some kind of laptop stand to raise up the keyboard to a more ergonomic angle and move the screen up as well, so you don't have to bend your neck as far forward to see it.

If you don't need the laptop to be raised very much (ie your neck is still very flexible) then a fairly effective stand can be fashioned from a sheet of cardboard. I'll put up a post later showing how to make one. In the mean time, I'll be considering commercial options which give you a lot more control, one per post (click here for a list).

When McKenzie doesn't work: Alkylosing Spondilitis

If you've tried the McKenzie extensions with little to no benefit (I did, for several years) maybe you don't have a slipped disk. There's at least one condition that doesn't respond to back extensions at all: Alkylosing Spondilitis. It's kind of like rheumatoid arthritis, but it targets your SI joints (and often other joints as well). One of the other diagnostic features is that your pain will sometimes switch sides, for no apparent reason. About 10% of back pain cases are due to Alkylosing Spondilitis. A more offical diagnosis depends on checking your blood for HLA-B27, though this is not conclusive. An MRI or, x-rays can also help make the diagnosis, though X-rays usually only show disease progression after 4 or more years after pain onset.

AS treatments include NSAIDS and Tumor necrosis factor-alpha supressors.

How much fish oil do I need to take for reduced pain?

Of course, it's not clear. A 2007 meta analysis of 17 studies of inflammatory pain (mostly rheumatoid arthritis) found repeated evidence that fish oil consumption caused improvements various measures, such as reduced joint stiffness, pain levels, and number of NSAIDs needed to reduce pain to a reasonable level. While aimed at fellow researchers and not chronic pain suffers, the following quote sums the issue up nicely:

"In order to maximize the therapeutic effects and improve the quality and validity of future trials, it is recommended that all studies report concomitant analgesics and doses since without these data it is difficult to assess the true magnitude of effect of ω-3 PUFA supplementation. In addition, we recommend use of high-dose ω-3 PUFAs (at least 2.7 g/day of EPA and DHA) for a minimum duration of 3 months using a non-olive oil placebo control condition."

Let me briefly explain what's going on here. First, different studies found fairly different levels of improvement, from quite significant, to rather minimal. The authors are suggesting that this may be due to how much other pain relievers (analgesics) participants were allowed to use (sometimes this data wasn't even reported). ω-3 PUFA (omega 3) is the type of polyunsaturated fatty acids in fish oil (and a few other oil types). Finally, they are suggesting that doses of less than 2.7g of ω-3 PUFAs don't consistently lead to improvements, so future studies should set that as the minimum dose. Note also that benefits are not necessarily seen right away, hence the suggestion that studies should be carried out for at least 3 months.

So how many capsules should you take? It's key to understand that a fish oil capsule is not 100% ω-3 PUFAs (epa + dha). Thus, to get 2.7g of omega 3's, you can't just take 3 1g capsules. Instead divide 2.7g by the amount of omega 3's. For instance, that would be 9 capsules of kirkland fish oil.

Note that 2.7g is the minimum. How much more is useful is unclear. Some evidence suggests that a little more, (3.6g) would be better, or even more than that (6g!), but without more research (and without better understanding of the potential downsides of taking that much), it's hard to recommend such a large dose.

PS. I am not an MD. Think for yourself, don't just blindly follow my advice.

Why a disc herniation does not mean you should get surgery

This well written article lays out the evidence that a herniated disk may in fact have little to do with your back pain.  Briefly, while many people with back pain do have herniated disks, a random sample of people without back pain revealed 17-52% had some level of herniation.  This means that 'fixing' a herniated disk with surgery doesn't necessarily mean that your pain will go away. A herniation need not cause any pain at all (probably it did when it first occurred, but the pain may not have lasted long).  I won't bother to summarize the article any farther, since it's quite well written (complete with references!).  Definitely an interesting read. 

Sitting more comfortably

As an office worker there's little I do everyday besides work at my computer. If only I could sit comfortably I'd be much happier with the job.  There are enough causes of back pain that what works for one person might not for the next, but here are some of the things I've done which help me. If they don't help you, just remember to keep on experimenting. Every 5-10% percent improvement is worth it!

1) mkenzie back roles help a lot. Almost any chair is made better by adding one. I've also found that paper towel roles can be useful, as they compress less than the mkenzie rolls.

2) Some amount of reclining can help. The worst possible thing is to sit in a chair that forces you to slump forward. 

3) getting your feet under you can help. IE if you have a chair without arms you can sit with your legs wide and your feet directly below your rear, pushing lightly on the ground. I find spending at least some of my sitting time this way helps. It's especially helpful if you have to sit in a bucket seat.

4) standing some of the time really helps. I have an elevated desk (about 4 feet off the floor) and this allows me to stand for 30 minutes at a time. It took a long time to adjust to this, but it's clear that it helps a lot to not sit all the time. On the other hand, it's critical to not stand all day. Esp. later in the day I need to mix standing with sitting.

5) trying the chair out before buying is pretty important. Just because it's expensive doesn't mean they made it lower back pain friendly! After many years of looking for  a better chair I've come to the conclusion that a $10 yoga ball from walmart is the best option for me.

Using google calendar to keep up with your exercises

It's hard to remember to do your exercises and stretches - but with google calendar, you can get reminder emails, and get the satisfaction of deleting those messages after you do each set of exercises. This is particularly helpful if you are doing an every-other-day exercise.  By having the reminders sent to your inbox, you ensure that your regular everyday practice of checking your email is all you need to get reminded. 

One of the tricks with lower back exercise (and stretches)  is to start at a very moderate level, and then ever so slowly increase the intensity and rep count. This ensures that you don't injure yourself. If you have trouble remembering to do your exercises, however, this slow ramp up process will never progress far enough to actually gain muscle strength and greater mobility.  This is one big reason why something like google calendar's reminders are so helpful.

To set up reminder emails, add an event to your calendar, and then click on "edit event details".  Set "Repeats" to weekly, and then check off the days you want. Then click on "Reminder" (under options) and set it to email you 10 minutes before (or whatever).  Try to add the event to our calendar around the time of day when you could actually do the exercise (the assumption being that you check your email pretty often). 

Back extension exercise

There are lots of websites which suggest a wide range of exercise and stretching for treating lower back pain. Heck, this is one of them. But do you ever wonder what evidence supports these exercises? I've decided to start reading the primary academic literature on back pain treatment, and summarizing the approaches which have more than anecdotal support. 

One of the old standards of lower back pain treatment is the back extension exercise.  The idea is to increase the strength of the muscles that allow you to bend backwards when you are lying on your stomach. At the same time, this helps with mobility, and supposedly can help improve blood flow to the disks and reduce pain by recalibrating the pain-sensitive sensory neurons in your back.  Because this exercise has been around for a while, there's lot of documented evidence that it can help chronic lower back pain. For more info, see this review article "Evidence-informed management of chronic low back pain with lumbar extensor strengthening exercises" published in 2008 in The Spine Journal (Note that a journal subscription is required, so you'll need to go to your local university library to read this, unless the following PDF link still works :-). This posting is largely based on the info in that artcle, so if you want more detail, be sure to check it out.

The back extension exercise can be done with a yoga ball (aka balance ball), as shown in the picture.  Face toward the floor, and place your hips on the ball. Trap your feet against a wall. Place your hands on your hips (or behind your head for more resistance), and bend backwards to the pain-free limit of your range. Be sure to take it slow and smooth, with about 2 seconds to bend backward, and 4 to return to the starting position. 

How often and with what intensity should you perform this exercise? Evidence suggests that doing a little is better than nothing, so you may see benefit with as little as 1 session a week, 3 sets of 6 reps, for a period of 12 weeks. If you want to work harder, build up slowly to 3 sessions a week, with 3 sets of 25 reps, but keep in mind you are much more at risk of injury, and like most back exercises doing a little is much better than doing a lot and then injuring yourself. Interestingly, there is little published evidence that doing the more intense workout leads to a significantly better outcome; I would guess that's because people tend to over-do it.

Once caveat that the 2008 journal article mentions is that there isn't conclusive evidence that the balance ball version of this exercise leads to a measurable strength gain that can help lower back pain. They recommend using gym equipment to ensure effectiveness, but I suspect here that doing the balance ball exercises religiously over 2 months will give more benefit than going to the gym 3 times and then losing motivation. In any case, here are some external links for more info - the first is a video instruction on how to do the exercise on a balance ball, and the second shows how to do the supposedly more effective version of the exercise on more specialized gym equipment. 

video - exercise on a balance ball

figure - exercise on a specialized equipment you might find in a gym.  You could duplicate this at home if you lay over the edge of a bench or bed, and have somebody to hold/sit on your legs.