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.

DIY: cheap icepack for your lower back

Whenever I do something physically stressful, like going on a fast walk, or anything that involves prolonged bending over or lifting, there's always a risk of pain afterwords. To lower that risk, I've found it very useful to apply an icepack to my lower back immediately after the exercise, even if there is as of yet no pain. To make this easier, you can make an icepack you can strap onto your back, allowing you to ice your back while still being able to move around the house. Here, I show you how to do that out of common household items.

The trick is to take a dress shirt, put a bag of peas just below the collar, and then tie the arms of the shirt around your wast. To demonstrate this more clearly, I recorded a video of how to do this.

Review and Recomendation: The Trigger Point Therapy Workbook

This is a review of Trigger Point massage, and a particular self-help book about applying the technique:  The Trigger Point Therapy Workbook by Clair Davies. I've been trying self-applied Trigger Point massage for a while now, using this book as my guide. I've found it to be a useful technique, and I recommend trying it. I've used it for back pain and hip pain, but the book contains sections for almost all areas of the body. 

The theory behind trigger point therapy is that muscles get knotted up in very specific locations in the body, and that the stress caused by these knots causes referred pain to nearby parts of the body where those muscles attach.  The Trigger Point Therapy Workbook  shows you where all these trigger points are, and the pattern of referred pain associated with each point. In addition, for each set of trigger points there is a lengthy discussion of the typical causes of problems at those points, how to locate the points by touch, and how to treat the trigger points. 

The treatment is almost always the same: high pressure massage of the muscle around the location of the trigger point. Exactly how the massage is done probably doesn't matter that much, so long as you get the spot right. The book's advice, however, can be helpful for figuring out how to get sufficient leverage and pressure for each point.  In many cases, the suggested massage tool is just a regular tennis ball, though sometimes more fancy tools like the thereacane are suggested. 

The book is a useful resource for finding the trigger points because the pain is usually referred. You may massage near the area of pain, but usually the actual point where the massage is needed is outside the area which aches. Interestingly, however, once you know the general area to search for the points, it's much easier to find them by touch than by religiously following the diagrams in the book. Nonetheless, the diagrams are important for figuring out the right areas to start searching. 

The book is very clearly written. It is intended to be read by pain sufferers, and while it doesn't dumb down the topic, care is taken to not be overly technical. It does suffer from overly grandiose claims for all the different conditions it might treat - in one section it even speculates that dyslexia may some day be treated by trigger point therapy.  Don't be too turned off, however, as in contrast to dyslexia, trigger point therapy really does seem to help chronic pain. On the other hand, I'm going to go out on a limb and suggest that there is less than 1% chance that trigger point therapy will ever provide a measurable help to dyslexics.  Oh well, like most self-help books you have to learn how to filter the good from the bad. 

In the end the book wouldn't be worth reading if it didn't help. Luckily, it does. In my own life, I've found that trigger point massage can significantly reduce my acute back pain around 30% of the time I apply it, and makes for at least some improvement almost every time I try it.  That's a pretty impressive level of improvement, in my book. It's well worth the $15 that it costs to buy it from Amazon (or other good online booksellers).  And, given that the only other tools you really need are a tennis ball, and perhaps a bottle opener, it's a very economical way to treat your pain.

Good posture for sitting

One of my reader's suggested I check out his website: www.lower-back-pain-toolkit.com. It turns out to have lots of interesting information, and has inspired me to put up a post about 'good' posture.

First, what is good sitting posture? The general/traditional view is that you want to sit upright, with a gentle s-curve in your lower spine from a lumbar role. See this link for a much more detailed discussion. Whenever this 'good' posture is illustrated, the person is almost always sitting with a 90 deg. angle between their legs and their torso. Undoubtedly, this is better than the forward slouch, where your back slowly curves forward and your chin ends up nearer your kneecaps than your hips.

This traditional view, however, may not be quite right, at least with respect to the 90 deg. angle between your hips and your back. MRI scans have revealed that when you sit in this posture, you actually put a lot of strain on the disks in your lower back. It may be significantly better to lean backward at a greater angle, such as 135 deg. See this BBC article for an example of this posture, and a short discussion of the science behind it.

In my personal experience, less than 90 deg. can quickly lead to pain. Exactly 90 deg. feels much better, at least in the short term. Greater than 90 deg. seems, however, to be the least painful of all. It can be hard to get a > 90 deg. position in a regular upright chair, however, without also leaving your back unsupported and hanging, leading to a reduction of lumbar lordosis. One way to avoid this is to role up a towel and sit on it. This will increase the angle between your hips and your back, while still maintaining the good lordosis. Another option is to slouch backwards, and then support your lower back by placing both of your arms behind your back.