News Category: Lumbar Spine

People with sacroiliac joint (SIJ) pain account for nearly one third of all back pain sufferers. The SIJ is the connection in the low back where the sacrum and pelvis bones meet. Physical therapists have long known that people with SIJ pain move and breathe differently from the average person. New information makes these differences clearer.

Many muscles, ligaments, and other tissues connect the bones around the SIJ. The stability of this joint depends on these supporting structures. It is this stability that allows the body to safely transfer the mechanical forces of movement through the low back and pelvic areas. These forces can be measured to see if the transfer of load is working as it should.

The test used to measure this is the “active straight-leg raise” (ASLR). Lying down on the back, the patient lifts the leg about an inch off the floor or table. Patients with SIJ pain either cannot lift the leg or report a severe “heaviness” of the leg. Therapists know that if they apply pressure through the pelvic bones, the patient can lift the leg easier. Somehow this kind of compression gives the pelvis the stability it needs for movement.

At the same time, breathing changes significantly in patients with SIJ pain. These changes aren’t always the same from person to person. They aren’t even the same for one person changing from one position to the next. Sometimes the number of breaths goes up or down. Other times, the patient holds the breath during the ASLR. Therapists are using tests and measures like this to help show what’s happening inside the body.

Stomach muscles, muscles used in breathing (such as the diaphragm), and muscles around the sacroiliac joint all work together. By coordinating their actions, these muscles can help stabilize the low back-sacroiliac area. When these muscles are disrupted, breathing changes, and the patient is unable to complete the ASLR.

Therapists can use this information to find ways to gain better control of the muscles around the sacroiliac joint. Improving the coordination of the stomach muscles with the diaphragm may help relieve sacroiliac joint pain.

Whether back belts protect workers from injury remains a hotly debated issue around the world. Many studies have suggested there’s no advantage to wearing a belt. These studies have raised a number of questions. Are back belts being worn properly? Is one belt more effective than others? Are the belts helpful for all loads or just certain types and amounts?

An occupational therapist in Taiwan teamed up with another researcher to take a fresh look at this issue. The researchers decided to measure trunk muscle activity using two different breathing techniques while lifting. One method was to breathe in and hold the breath while lifting. The other was to breathe out while lifting. The belt used was carefully controlled. Belt pressure was adjusted to three different settings. All three belt pressures were included in the study.

The idea was to look at the effect of belt pressure on breathing and trunk muscle activity during repetitive lifting. Would different belt pressures result in different muscle activity? Would belt pressure affect the stomach muscles? Would different breathing methods affect back muscle activity? This study was different from past studies because the researchers looked at two kinds of pressure: belt pressure and pressure from holding the breath.

In this study, the belt did reduce the use of back muscles. The researchers thought this positive result might be due to the kind of belt used and the way it was used. An elastic belt with a high width and four semi-rigid bars was carefully fitted by an occupational therapist. Researchers also found that the stomach muscles helped out the back muscles during lifting.

Whether back belts prevent back injuries remains in question. Many studies have been done, with varying results. This study showed that controlling both air volume and belt pressure while lifting benefits the back. It may be that belt type and proper usage contribute to a better result. More studies are needed before the question of back belts is resolved.

Many studies have tried to identify what causes low back pain–especially disc problems. Once risk factors for disc herniation have been found, steps can be taken to prevent this problem.

A number of causes have been suggested. These include inactivity on the job, accidental back injury, motor vehicle accidents, and smoking. Certain types of work seem to cause disc problems, such as frequent exposure to vibration, heavy lifting, and twisting and bending. Work stress and mental stress have been added to the list. More recently, genetic factors have been found to cause low back pain.

A recent study looked at 41 people who had mild to moderate disc degeneration but no symptoms. An MRI (magnetic resonance imaging) was done and repeated five years later. Within those five years, almost half of the patients showed a worsening of the disc. The disc protruded outside its normal space.

What made the disc get worse? Instead of the classic risk factors already mentioned, researchers found something new and different. Lack of sports activity, or less physical activity during leisure time, was a major risk factor for these people. Evening or night-shift work was another risk factor, with more absences from work as the disc got worse. There was also a link between the amount of disc herniation at first and how bad the problem got over time.

According to this study, disc problems can get worse based on three factors: lack of physical activity, evening or night work, and the amount of disc herniation at the time of injury. These three risk factors are new and different from what previous studies have shown. This study suggests that the classic occupational risk factors of heavy lifting, twisting and bending, and exposure to vibration have been given too much credit for making bad backs worse.

Disc problems probably have more to do with genetic and environmental factors than anything else. Though we can’t escape genetics, more exercise and different work hours may keep disc problems in check.

Say your child or adolescent has back surgery. How soon can he or she go back to sports? Are there any sports or activities that should be avoided, and for how long? What do most doctors recommend?

Ten physicians who are members of the Scoliosis Research Society were given surveys to fill out. Questions concerned children and adolescents who had back surgery for any reason. Most of the patients had the spine fused because of scoliosis (curvature of the spine). The questions were designed to tell researchers what advice doctors give about children’s activity after back surgery.

Despite the small number of doctors in the study, there was a wide range of responses. There was not very much agreement about either recommended or forbidden activities. The most popular time to go back to sports was six months after surgery. This was for low-impact, noncontact activities. Contact sports were generally allowed at 12 months.

About half of the doctors advised against collision sports. This advice was given on an individual basis, depending on the age of the patient, the kind of surgery done, and the time since surgery. Activities to avoid included gymnastics, football and rugby, weight lifting, skydiving, bungee jumping, parachuting, playing on a trampoline, hang gliding, and rodeo.

Specific guidelines for returning to sports after back surgery are not yet available. Doctors’ advice comes from their own experience and what they’ve been taught. Learning more about current practice will help researchers set guidelines in this area.

There is a new direction for medical treatment these days. It’s called “evidence-based treatment.” Insurance companies, health care groups, and government agencies are demanding proof that medical treatments actually work.

This new move is taking hold in the United States and many other countries. In Australia, the first study of evidence-based treatment of low back pain has been reported. Two groups of people with back pain were studied. The first group received care from a medical specialist with advanced training in muscle or bone injuries. The second group was seen by their regular doctor, usually a general practitioner.

The medical specialists used a specific treatment program. The treatment guidelines were decided by reviewing all the reports and articles available on the treatment of low back pain. Evidence-based practice included use of a formal home program, manual therapy by the doctor, and injections into painful muscles. The general practitioners provided their usual care of X-rays, anti-inflammatory drugs, heat, and rest.

Nurses interviewed everyone in both groups during and after treatment at three, six, and 12 months. The nurses talked with patients in the clinic and later at home visits. At three months, there wasn’t much difference between the two groups. By six and 12 months, the evidence-based treatment group showed a faster, fuller recovery with less pain and return of symptoms.

There were cost differences, too. General practitioners spent more money ordering X-rays and imaging studies. The medical specialist group had fewer patients returning with back pain, so there was less cost in the long run. The average cost per patient in the general care group was $472 (Australian) compared to $276 in the specialist group.

It’s still not clear whether the evidence-based guidelines made the difference. Is the actual treatment more effective? Or do patients have greater confidence in specialists? The majority of patients in the evidence-based clinics gave their care excellent ratings. Less than half of the patients in general care gave their treatment such high ratings.

Most interesting of all were the comments of patients in the evidence-based group. They said that pain and symptom relief weren’t nearly as important as the reassurance and sense of power they’d received. Some of these people were completely satisfied with their care even though they still had pain. Tried-and-true treatments clearly have a greater impact on back pain and patients with back pain.

Spinal fusion surgery is often used to treat back pain. But even when the vertebra are successfully joined together, this surgery only relieves pain about 70 percent of the time. Doctors would like to be able to predict who benefits from this type of surgery (called “arthrodesis”). That way, they can avoid doing surgery on patients who will get little or no benefit.

Past research suggests that external fixation may predict whether patients feel better after surgery. With external fixation, a metal device is placed over the outside of the patient’s back. Screws are inserted into the back of the spinal column above and below the sections that are to be fused together. This is done while the patient is asleep from anesthesia. External fixation was first used to heal breaks in the spine. It has since been found to reduce back pain by holding the spine in place. This author wanted to see whether patients who got relief from this procedure before spinal fusion surgery would go on to have good results after surgery. 

External fixations were tried on 103 patients. Patients averaged 45 years old. One hundred procedures were completed. Nerve complications occurred in two procedures; one of these led to permanent problems. Five patients had infections. Infections were rare when patients had antibiotic treatment while wearing the fixation device. Devices were removed after two weeks.

Sixty patients had pain relief with external fixation. These patients were thought to be good candidates for spinal fusion surgery. Forty-nine patients went on to have the surgery. They were then observed for at least one year.

Did patients who felt better from external fixation have good results from surgery? Though the fusions were successful, only about half of the patients had enough pain relief to show better function at follow-up. About a third of the patients felt the same after surgery. And eight percent were actually doing worse.

From these results, the author concludes that external fixation should not be used to decide which patients will benefit from surgery to fuse the spine. External fixation can have complications. Other procedures may be more successful in deciding who gets good results from spine surgery.

If you see a doctor for low back pain, he or she may ask you to look at a scale from zero (no pain at all) to 100 (the worst pain imaginable) and point to the place that best describes your pain. This is called a “visual analog scale,” or VAS. Doctors often use VAS to measure the intensity of patients’ pain. This helps doctors suggest appropriate treatment. They also use VAS after surgery, to see whether pain has gone down.

Though VAS is popular, there are still questions about how to use it and exactly what it measures. Are pain scores from VAS related to other measures of patient outcomes, such as use of painkillers and patient satisfaction?

Seven hundred fifty-five patients had surgery for low back pain. Patients ranged in age from 15 to 86, with an average of 50. There were slightly more men than women.

Before surgery and four and 12 months after, patients rated their back and leg pain using VAS. Use of painkillers was also recorded. After surgery, patients were asked whether their back and leg pain had changed, and whether they were satisfied with their results.

Before surgery, patients with different diagnoses showed distinct patterns of pain. The authors were surprised just how clear-cut these patterns were. Patients with herniated discs (roughly half of the patients) had minor back pain but strong leg pain. Patients who had narrowing inside the spinal canal had moderate back pain and strong leg pain. Patients whose vertebra had dislodged and slid forward had moderate back pain and minor leg pain. Patients who had degenerative disc disease had the most back pain of any group, along with minor leg pain.

Pain improved by the four-month follow-up for all of these conditions. Twelve months after surgery, patient satisfaction was related to all of the pain measures in this study (VAS pain scores, the change-in-pain question, and use of painkillers). Notably, patient satisfaction was the most closely related to VAS scores after surgery and direct questions about changes in pain. This suggests that comparing before-and-after pain scores from VAS may not be the best way to measure patients’ results. It may be preferable to examine VAS scores after surgery alone or to simply ask patients about changes in pain.

So what’s the best bet for gauging patients’ results from surgery? The authors can’t say. They’re not even sure this “best bet” question is the right one to ask. Though measures of pain are related to each other, each measures something slightly different. Certainly, the way pain is measured matters. It’s important to keep this in mind when comparing treatment results that are described in terms of changes in pain.

Back pain strikes! What will help you the most? A long rest and staying away from work? Or keeping active, exercising, and not resting for long? We know which sounds more appealing, but in fact many studies have proven that staying active and on the job has the best outcome.

Disability from low back pain is on the rise and has become a worldwide problem. Medical groups like the Workers’ Compensation organization (WorkCover Authority) in Australia are looking for ways to change this. This group began the first public program to change the way people think about back pain. The program was also designed to change the way doctors manage back pain. The overall goal was to prevent disability and reduce the cost to workers’ compensation.

Using different forms of publicity, this group tried to reach the general public with this message. They used television commercials, pamphlets, billboards, posters, workplace visits, and publicity articles to accomplish this goal. They measured their success by calling thousands of individuals and doctors on the telephone before and after the program. They asked everyone the same questions about beliefs and actions related to back pain.

The researchers found that no matter a person’s age, salary, birthplace, sex, or educational level, there was a definite change in attitude. The management of back pain by general doctors also changed in keeping with the advertised message. Fear and avoidance of activity were reduced in response to this new information. Best of all, the number of back claims decreased by 15 percent, with an overall cost decrease of 20 percent per claim.

Positive messages about back pain can alter the way people think about this problem. Information and advice given to the general public can help change society’s response to that first case of sudden back pain. More information on back care and back pain prevention is available. Helpful resources include:

•  The Back Book by M. Roland, G. Waddell, and J. Moffat. Published by The Stationary Office, London, United Kingdom (England), 1996.


•  Treat Your Own Back (7th edition) by Robin McKenzie. Published by McKenzie Institute. This resource is available online at www.mckenziemdt.org, or by calling 800-635-8380 (USA).

Patients with chronic low back pain often have low levels of activity. Most say pain keeps them from doing activities. But researchers have found that patients’ pain isn’t always linked to their physical performance. What other factors might get in the way of activity? Does emotional well-being have anything to do with it?

These authors tested 75 patients with chronic low back pain using a treadmill. The patients averaged 40 years old. They’d had back pain for about three years. The patients were told to walk on the treadmill as long as they could at three different speeds and inclines. Patients reported their amount of pain on a scale from zero to ten before and after the treadmill test. Patients’ walking times and physical fitness were recorded. Patients also filled out a mental health questionnaire.

Pain went up after walking. Patients with more pain walked for shorter periods of time. Older patients also walked less. Patients’ gender and history with back pain didn’t make any difference in how long they walked.

About half of the patients were said to have low mental health. This was determined when patients’ responses on the questionnaire showed depression, anxiety, loss of self-control, and lack of well-being. Compared to the other patients, these patients were more likely to be on disability and have lower incomes. However, patients with low mental health reported about the same amount of pain before and after the treadmill test as the “mentally healthy” patients. Patients with low mental health were equally fit as the other patients and walked about the same amount of time.

What stopped patients from walking? Roughly half stopped because of pain. Not surprisingly, patients who stopped because of pain had higher pain scores than those who stopped because of fatigue. Patients who stopped because of pain walked fewer minutes, though they were equally fit as the patients who stopped because they got tired.

Patients who stopped walking because of pain were more likely to have low mental health scores. However, mental health wasn’t related to how long patients walked on the treadmill; pain was. This suggests that poor mental health is a result (not a cause) of the pain patients experience with physical activity.

Health professionals have different theories about how chronic pain affects mood and behavior. One theory is that mood determines behavior. (You don’t feel good emotionally, so you don’t perform well physically.) The other theory is that pain gets in the way of physical performance, which then affects mood. (You don’t feel good or do well physically, which makes you feel bad emotionally.) This study supports the second theory more than the first. In terms of physical performance, patients’ reason for stopping on the treadmill (pain) was more important than their mental health.

Pain is a common reason that patients drop out of treatment programs involving physical activity. The authors are investigating whether patients who have relatively more pain in physical activity are the ones who drop out of treatment, and whether their physical performance improves with treatment.

Are you at risk for a back injury? The most common predictor of back injury for all adults is a previous or current low back injury. This is true for the general population and for athletes. For adults, job dissatisfaction and previous or current low back injury are two of the most well-known risk factors. For athletes, dissatisfaction with coaching staff or team players does not seem to have any relation to back injury.

In a study of 679 college athletes, “back injury” was defined as any low back pain that caused an athlete to miss part or all of practice or games on three separate occasions. In addition, athletes had to be seen by a sports physician. Ninety percent of these injuries were sports-related.

Athletes who had low back pain were three to six times more likely to have another back injury in the following season or year. This was true for both men and women, and for contact and noncontact sports.

This is an important finding for players, coaches, and trainers. It should be strongly considered during the preseason sports screening. Back injury usually involves the soft tissues such as ligaments and muscles. Injury to these structures can change how quickly the muscles contract. When the trunk muscles take extra time to respond to a sudden load, injury is more likely.

Designing a program of preventive exercises may be helpful, even for athletes who have already returned to competition. Such a program takes into consideration that the ability to make sudden movements may not be immediately restored after a back injury.

Bend your knees when lifting! Most people have heard this advice by now. But how much bend is enough? Is it better to do a full squat or a semi-squat? Is it better to put more stress on your back or your knees?

Lifting injuries to the low back are common in the workplace. These can happen from lifting unexpected loads, slipping during lifting, or even falling while lifting objects. Recently, researchers have looked at how lifting an unexpectedly heavy load affects balance.

Two groups of healthy male volunteers were recruited to compare lifting techniques. One group used a deep squat with a straight back to lift objects. The other group used a semi-squat and leaned forward (stooped) when necessary. When the load was heavier than expected, the group using the full squat and erect posture was more likely to lose balance and fall forward.

Losing balance usually means dropping or returning the load to the ground. On a second attempt to lift the same object, jerking motions are used that can increase the risk of back injury. Researchers also showed that the muscles’ reaction to an unexpected weight is important. This is true on the first attempt to lift and on the second try. Whenever possible, using smooth muscle movements (instead of jerky motions) reduces the risk of injury.

Lifting technique does make a difference, especially when lifting an unexpectedly heavy load. Using a deeper knee bend and keeping the back straight may cause a loss of balance. This risk is reduced in these instances by using a semi-squat and slightly stooped posture.

Sciatica is low back pain that goes into the buttock and travels down the back of the leg. The most common cause of sciatica is pressure on a nerve from a protruding or herniated disc. The disc is a spongy or jelly-like structure between the bones of the spine. It acts as a cushion and shock absorber. Injury to the back or degeneration from aging can cause the disc to push out of its own space and press against the spinal nerve. Pain from sciatica can result.

Sciatica is a fairly common problem with some major side effects. Pain, change in sensation, and muscle weakness can result in disability at home and at work. Loss of work time and medical expenses can create a financial burden. For these reasons, doctors have been looking for better, faster, and less expensive ways to treat sciatica.

Steroid injections for sciatica have been used for a long time. The success of these injections ranges from 20 to 100 percent. Injections are often helpful, but they may only last three months. Today’s new imaging technology is making a difference in the success rate of this technique. Using a type of X-ray called fluoroscopy, doctors can see where the needle is inserted and where the medication is placed.

In the past, injections into the spine have been performed blindly. In other words, doctors guided the needle according to their knowledge of anatomy, without actually seeing inside.
The new X-ray method is more accurate. It gets more of the medication to the place where the disc is squeezing on the nerve. Applying the medication to the site of nerve irritation has better results. It also has fewer complications. Being able to see where they’re going has made it possible for doctors to work around any unusual structures or scar tissue.

Injections using fluoroscopy shows better results when treating sciatica. The long-term outcomes are even better when injections are followed by physical therapy and stabilization exercises for the low back.

You might think athletes are less likely to have low back pain than the average person. After all, they’re in such good shape! But in reality, athletes of all kinds are at greater risk for back pain because of previous sports injuries. For example, a leg injury changes the way the body moves from the leg up to the back. Athletes with leg injuries from overuse or ligament damage are more likely to need treatment for back pain.

To combat injuries of the back and legs, athletes often follow a specific training regimen. This group of exercises is called the “core-strengthening program.” It includes exercises for the muscles of the trunk, spine, and hips. These exercises are done four to five times each week during the preseason, and two to three times per week during the season. Each exercise session takes 30 to 45 minutes to complete.

This kind of supervised program has been recommended and used for years. However, there has been no research to show that it’s really effective. A group of researchers decided to test this program. They looked at the impact of a core-strengthening program on the amount of low back pain in college athletes. To do this, they divided athletes into two groups and followed them for two years.

Each of the athletes had a physical exam before starting. Also, their hip extensor muscles were tested for strength. The first group of athletes did the core-strengthening exercises. The second group did not participate in this program but did a training program for their sport. The number of athletes treated for low back pain was recorded. The results were compared for men and women.

In this study, the core-strengthening program did not significantly affect the number of athletes who developed low back pain. Although there was a reduction in the number of male athletes who had low back pain after the program, this difference was felt to be slight. As a group, low back pain among the female athletes was not impacted by core strengthening. The authors attribute this to the possible need for improved hip strength in this group of women athletes.

More studies of this kind with more participants are needed before any real conclusions can be made. It may be that training exercises in sports should be different for men and women. Notably, only one set of muscles was tested in this study. Improvement in other muscle groups such as the abdominal muscles may have affected the low back, but these were not tested. Future studies may look at each muscle group and compare before and after results for both men and women.

Sometimes the spine needs a little extra help staying in place. This may call for a device that screws into the bones on either side of a weak spot, or internal fixation device. Doctors use this device for spine fractures, abnormal spine curves, and for injured or degenerated discs.

It’s important to start moving again as soon as possible after any surgery. Physical therapy often begins within the first few days after spine surgery. Exercises are prescribed to improve muscle strength without putting too much load on the healing bone. With spinal fixation devices, there’s always the worry that a screw will break under a heavy load. This happens in less than 10 percent of all cases, but when it happens, it is a serious complication.

How much load is too much? How much movement is safe? One group of researchers has done many studies to measure the spinal loads for different activities. Load can be accurately measured by using an implant that records and transmits signals. Load has been measured for such common activities as sitting, lying down, standing, walking, lifting one leg, lifting one arm, rising up on tiptoes, and turning over in bed.

The strength of spinal screws has also been tested. The manufacturer has given doctors and researchers the amount of force implants can handle without breaking. This amount is 110 percent of the maximum load on the spine while standing. This means the screws can withstand 10 percent more than the maximum force put on the spine when standing. Any activity that loads the spine less than this is considered safe. At this level, spine fracture or screw breakage is not likely.

Movements that exceed this load include walking, and bending forward or backward in the standing position. For example, bending forward in the standing position increases the pressure on the spine more than twice as much as standing. The risk of screws breaking is greater if these movements are done often. Placing the screws farther apart during surgery can also put the spine at greater risk.

Getting people up and moving after surgery that fixes the spine in place with screws may be risky. The forces placed on the screws while standing are safe, but walking appears to place a higher load on the screws. Other activities such as sitting, rolling, or crawling on hands and knees appear to have much lower loads than walking. More information of this kind will help physical therapists plan safe and effective rehabilitation programs following spinal surgery with fixation devices.

Every year, thousands of adults suffer one or more periods of low back pain. Days off from work or school equal millions of dollars lost. Researchers are working hard to find ways to prevent low back pain. Perhaps looking at younger people can give some clues. One group of Swedish scientists measured back strength and motion of the spine to see if these would predict low back pain later.

Before starting a research project, most scientists read all the articles already published on the subject. At the time of this Swedish project, there were only a few studies on low back pain in teenagers. Results weren’t consistent from one study to the next. There was agreement that increasing age, long periods of sitting, and high levels of physical activity increased the risk for low back pain. Other risk factors were stress and low back pain in the family. Girls seemed to have more low back pain than boys, as do women compared to men.

In the Swedish study, 88 teenagers (14 to 16 years old) were interviewed and measured. Back measurements included bending back and forth, and holding a position for four minutes (strength). Various other measures were also taken to see if they had any connection to low back pain. These included height, weight, parental back pain, mood, fitness level, and time spent on a computer or watching television.

For these teenagers, low back pain did not appear to be related to height, weight, or back pain in parents. Girls reported back pain more often than boys. This was not related to menstrual pain. Time spent on a computer or watching television was associated with low back pain when the study began but not at the follow-up three years later.

Low back pain for the whole group was present when back strength was low. For girls, a combination of decreased back strength and increased spinal motion was reported. Among boys, low back pain and low strength went together.

Even though this was a small study, the information is useful. If doctors can predict which teenagers are more likely to have back problems later, they may be able to prevent back pain. Starting a back-pain prevention program for younger ages may be a good solution. Improving back strength while teaching students to avoid certain positions is another practical suggestion. Some schools are adjusting furniture for taller students. The results of these prevention efforts have yet to be reported.

Low back pain is very common in the United States and causes disabling problems for many adults. Despite today’s technology and new ways to look inside the body, it’s still a mystery why the back “goes out.” Until we know what causes muscle injury, it is difficult to prevent or treat it.

There is a new push in medicine for doctors, physical therapists, and other scientists to find out what causes back pain. So far, it looks like the muscles of the back hold the key. When the muscles don’t function properly, the spine is at risk for injury.

Studying the muscles of the back or spine, it seems that there are two major groups. One group is the deep and short muscles that go between two or three bones of the spine. The second group is the long muscles that cross many vertebrae. By working together, the short and long muscles protect the discs, ligaments, and joints of the spine from injury.

Other muscles are also important in holding the back stable, especially with so much daily bending and strain. The abdominal muscles give support and pressure much like a corset or girdle. This tension keeps the bones of the spine from sliding sideways or turning when they shouldn’t. Even the diaphragm, the muscle that goes up and down with breathing, appears to add pressure to support the back. All of these muscles work together to safely hold the spine steady during daily activities.

The muscles of the back and abdomen also act as tension springs to hold the spine stable. For example, when the spine is stressed too much, muscles on either side of the spine contract together at the same time. This is called cocontraction. This keeps the back in balance when carrying heavy items, repeating the same movement over and over, or making a sudden movement.

Muscle training has been shown to have a positive effect on the back. How this works is still largely a mystery. This type of training appears to increase muscle strength and endurance, improve muscle coordination, and improve posture. All of these together may help prevent back injuries. Scientists will continue to study each muscle group in the backs of healthy adults. By comparing this information with similar studies of injured back muscles, better treatment for back pain is possible.

Not much is known about what causes back injuries in golfers. Yet back injuries are the most common musculoskeletal problem among amateurs and professionals in the sport. Some say golfers’ back injuries are caused by a poor swing. Others think injuries come from excessive practice and poor physical shape. Professional golfers have twice as many injuries to the low back area compared to amateur golfers. It’s possible that long practice sessions and repeating the same motions over and over may lead to back injuries.

A lot happens in the trunk of the body during a golf swing. The trunk has to twist considerably. The low back and abdominal muscles must work together to steady the spine and accelerate the club head. Perhaps this one-sided movement puts too much stress on the low back, leading to injury and pain. Researchers have shown that the abdominal muscles produce much of the power needed for a strong golf swing. Fatigue of these muscles may be the problem.

Researchers set out to measure abdominal muscle activity and compare it in golfers with and without back pain. They thought that elite male golfers with chronic low back pain would have less abdominal muscle activity during the golf swing. They found out it’s not the amount of abdominal activity that matters. They also discovered it’s not abdominal muscle fatigue that contributes to back injuries. It is the timing of when one part of the abdominals starts to contract!

Eighteen male professional golfers and seven elite amateurs (less than a five handicap) participated in this study. By placing electrodes on the skin over the abdominal muscles, researchers measured when and how much these muscles contracted during the golf swing.

The abdominal muscles are divided into three parts: rectus abdominis, internal oblique, and external oblique muscles. The rectus abdominis muscle goes straight up and down the middle of the abdomen from the lower ribs to the pelvic bone. The internal oblique muscles wrap around the trunk like a girdle, and the external oblique muscles come from the side of the ribs in a downward diagonal. These three sets of muscles work together to move the trunk or hold the back stable.

There were no differences in how and when the rectus abdominis or internal oblique muscles worked between golfers with back pain and those without. In the golfers with back pain, the external oblique (EO) muscles were delayed in starting to contract during the back-swing motion. This means that for the right-handed golfer, the EO muscles on the left side of the body didn’t start to turn the front of the body to the right when they should have (the action needed at the start of a right-handed golf swing).

Would changing the golf swing or doing more abdominal exercises make a difference in back pain? Researchers can’t say. Future studies to measure muscle endurance and look for other causes of low back pain among golfers may bring the answers.

Why do some people with painful conditions recover while others go on to have chronic, disabling pain? It may have to do with patients’ fear of pain and how they deal with it.

Patients’ fear of pain is determined by a variety of factors, including their personality, coping skills, and history with pain and stress. Response to pain can range from confrontation to avoidance. With confrontation, patients gradually return to their regular activities after a traumatic event. This is seen as a healthy response. With avoidance, patients steer clear of activities they think will cause pain. This can lead to exaggerated notions of pain and increased disability over time.

Avoidance behavior has been linked to more disability and work loss in patients with low back pain and other painful conditions. In fact, researchers think that “fear of pain and what we do about it may be more disabling than pain itself.” However, the role of “fear-avoidance beliefs”–beliefs that activities will lead to pain–has not been studied in patients with neck pain. Does fear also affect the recovery of patients with neck pain?

To find out, these authors measured pain, disability, and fear of activities in 59 patients with neck pain and 104 patients with low back pain. Patients in the neck group had generally been in pain longer; however, they had less disability than patients with low back pain. Patients with neck pain also tended to be a little younger, with an average age of 40 (versus 45 in the low back group).

Compared to patients with neck pain, patients with low back pain seemed to have more fear of physical and work activities. This was particularly true for patients getting worker’s comp. For patients injured on the job, low back pain led to more fear of work activities than did neck pain.

Fear of physical activities was related to disability for both groups. For the low back group, fear of work activities was also linked to disability. This wasn’t true for the neck group. It may be that patients have a greater fear of re-injury when the pain is in the low back. For patients in the neck group, amount of pain wasn’t linked to disability or fear of activities the same way it was for the low back group.

Patients tended to have more fear of activities when they were getting work or auto compensation. These patients were probably injured while working or driving and may have been fearful of resuming these activities.

Men showed more fear of activities than women. Patients whose symptoms had come on quickly also had more fear of activities. To a lesser degree, patients with newer (more acute) pain were more fearful of activities than those with chronic pain.

In the case of low back pain, fear of physical and work activities seems to keep patients from full recovery. But fear of activities doesn’t seem to play the same role for patients with neck pain. Researchers will have to keep looking for the “psychosocial” factors that affect patients’ recovery from neck pain.

Do back patients who expect treatment to help them get better than those who don’t? Many doctors, physical therapists, and researchers think so. Scientists haven’t been able to prove it yet. A new study from the University of California, Los Angeles, can shed some light on this topic.

In this study, 681 patients with low back pain were treated in one of four groups. The groups included medical care with and without physical therapy, and chiropractic care with and without physical modalities. Modalities included heat, cold, ultrasound, and electrical muscle stimulation.

Researchers found that patients getting medical care with physical therapy had the best results. They think this is because these patients received the most contact (31 minutes instead of 14 minutes with other treatments). The therapists told patients what to expect from the treatment. Education about back care was also included by the physical therapists.

Patients who had back pain the longest were less likely to expect good results. On the other hand, older patients, women, and nonwhites had high levels of belief that treatment would work. This may be because these patients accept the authority of a doctor or therapist.

Are the results of all types of therapy based on patient’s beliefs about what will happen? We don’t know yet. This is the next step for researchers to explore.

Much is known about the benefits of physical therapy for chronic low back pain. It’s also evident that patients who take part in a program of physical activity after spinal surgery fare best. Clearly, getting the joints and muscles moving and the heart and lungs pumping improve the health of patients with back pain.

If activities to get back patients moving are so helpful, what about treatments that get their nerves moving? This specialized form of treatment, called neural mobilization has gained popularity over the past ten years among physical therapists. It involves positioning and moving the spine and/or limbs to tug or stretch on nerve tissues. It is often helpful in relieving pain, especially chronic pain. Till recently, however, only one study addressed its ability to help patients after low back surgery.

The reason for doing nerve mobilization after spine surgery seems compelling at first. Patients sometimes heal by forming too much scar tissue where the nerve roots exit the spinal column. Nerves that are bound down by scar tissue may become sensitive, leading to more pain and problems. Keeping the nerve roots mobile, then, might improve surgery results.

Despite apparently sound reasoning, science shows otherwise. It is now evident that this type of treatment adds no additional benefit when used after lower spine surgery.

Patients having low back surgery were randomly placed in two groups. Starting on day one, both groups did standard exercises after surgery. One group also received neural mobilization treatments. Upon leaving the hospital, all patients were given a sheet of exercises to do. Those getting the nerve treatments were shown how to do the techniques on their own. Patients were instructed to keep up with their home program for another six weeks.

Several times over the course of a year, patients were asked about their pain and abilities, and whether they’d gotten back to work or other activities. Using these measures, the authors determined that neural mobilization had no benefit when added to standard care after spinal surgery. The results were not clear on whether nerve mobilization might even be harmful when used after spinal surgery.

The authors conclude that the nerve mobilizations described in their research should not be used on patients in the early weeks after low back surgery. Given these results, the authors insist that further studies of this nature need not be conducted.