Lower Back Pain

LOWER BACK PAIN (Project Work)

By AFRANA

SYIEMLIEH BPT (internship) Krupanidhi College of Physiotherapy Submitted to Dr. Deepshika Baruah (HOD) Little Sisters of the Poor

Date: 27th November 2009 ANATOMY OF THE LOW BACK Important structures of the low back includes the bony lumbar spine (vertebrae), discs between the vertebrae, ligaments around the spine and discs, spinal cord and nerves, muscles of the low back, internal organs of the pelvis and abdomen, and the skin covering the lumbar area.

• Bony lumbar spine (vertebrae) - is designed so that vertebrae "stacked" together can provide a movable support structure while also protecting the spinal cord (nervous tissue that extends down the spinal column from the brain) from injury. Each vertebrae has a spinous process, a bony prominence behind the spinal cord, which shields the cord's nervous tissue. They also have a strong bony "body" in front of the spinal cord to provide a platform suitable for weight bearing of all tissues above the buttocks. The lumbar vertebrae stack immediately atop the sacrum bone in between the buttocks. On each side, the sacrum meets the iliac bone of the pelvis to form the sacroiliac joint of the buttock. • Discs -The discs are pads that serve as "cushions" between each vertebral body. They help to minimize the impact of stress forces on the spinal column. Each disc is designed like a jelly donut with a central softer component (nucleus pulposus) and a surrounding outer ring (annulus fibrosus). The central portion of the disc is capable of rupturing (herniating) through the outer ring, causing irritation of adjacent nervous tissue and sciatica, as described below. • Ligaments -Ligaments are strong fibrous soft tissues that firmly attach bones to bones. Ligaments attach each of the vertebrae and surround each of the discs. • Spinal cord and Nerves -The nerves that provide sensation and stimulate the muscles of the low back as well as the lower extremities (the thighs, legs, feet, and toes) exit the spinal column through bony portals called "foramen. • Muscles - Many muscle groups that are responsible for flexing, extending, and rotating the waist, as well as moving the lower extremities, attach to the lumbar spine through tendon insertions. • Internal organs of the pelvis and abdomen -The aorta and blood vessels that transport blood to and from the lower extremities pass in front of the lumbar spine in the abdomen and pelvis. Surrounding these blood vessels are lymph glands and involuntary nervous system tissues, which are important in maintaining bladder and bowel control. The uterus and ovaries are important pelvic structures in front of the pelvic area of women. The prostate gland is a significant pelvic structure in men. The kidneys are on either side of the back of the lower abdomen, in front of the lumbar spine. • Skin -The skin over the lumbar area is supplied by nerves that come from nerve roots that exit from the lumbar spine. FUNCTIONS OF THE LOW BACK The low back, or lumbar area, serves a number of important functions for the human body. These functions include structural support, movement, and protection of certain body tissues.

When we stand, the lower back is functioning to hold most of the weight of the body. When we bend, extend or rotate at the waist, the lower back is involved in the movement. Therefore, injury to the structures important for weight bearing, such as the bony spine, muscles, tendons, and ligaments, often can be detected when the body is standing erect or used in various movements. Protecting the soft tissues of the nervous system and spinal cord as well as nearby organs of the pelvis and abdomen is a critical function the lumbar spine and its adjacent muscles. DEFINITION OF LOW BACK PAIN Low back pain (LBP) is a common complaint—second only to cold and flu as a reason why patients seek care from their family doctor. It may be a limited musculoskeletal symptom or caused by a variety of diseases and disorders that affect or extend from the lumbar spine. Low back pain is sometimes accompanied by sciatica, which is pain that involves the sciatic nerve and is felt in the lower back, the buttocks, the backs and sides of the thighs, and possibly the calves. More serious causes of LBP may be accompanied by fever, night pain that awakens a person from sleep, loss of bladder or bowel control, numbness, burning urination, swelling or sharp pain. COMMON CAUSES OF LOW BACK PAIN There are several causes of low back pain (sometimes referred to as Lumbago). Some of the common causes are listed below. 1 .LUMBAR STRAIN (acute, chronic) A lumbar strain is a stretching injury to the ligaments, tendons, and/or muscles of the low back. The stretching incident results in microscopic tears of varying degrees in these tissues. Lumbar strain is considered one of the most common causes of low back pain. The injury can occur because of overuse, improper use, or trauma. Soft-tissue injury is commonly classified as "acute" if it has been present for days to weeks. If the strain lasts longer than three months, it is referred to as "chronic." Lumbar strain most often occurs in people in their forties, but it can happen at any age. The condition is characterized by localized discomfort in the low back area with onset after an event that mechanically stressed the lumbar tissues. The severity of the injury ranges from mild to severe, depending on the degree of strain and resulting spasm of the muscles of the low back. 2.

NERVE IRRITATION The nerves of the lumbar spine can be irritated by mechanical impingement or disease any where along their paths—from their roots at the spinal cord to the skin surface. These conditions include lumbar disc disease (radiculopathy), bony encroachment, and inflammation of the nerves caused by a viral infection (shingles).

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LUMBAR RADICULOPATHY Lumbar radiculopathy is nerve irritation that is caused by damage to the discs between the vertebrae. Damage to the disc occurs because of degeneration ("wear and tear") of the outer ring of the disc, traumatic injury, or both. As a result, the central softer portion of the disc can rupture (herniate) through the outer ring of the disc and abut the spinal cord or its nerves as they exit the bony spinal column. This rupture is what causes the commonly recognized "sciatica" pain that shoots down the leg. Sciatica can be preceded by a history of localized low-back aching or it can follow a "popping" sensation and be accompanied by numbness and tingling. The pain commonly increases with movements at the waist and can increase with coughing or sneezing. In more severe instances, sciatica can be accompanied by incontinence of the bladder and/or bowels. BONY ENCROACHMENT Any condition that results in movement or growth of the vertebrae of the lumbar spine can limit the space (encroachment) for the adjacent spinal cord and nerves. Causes of bony encroachment of the spinal nerves include foraminal narrowing (narrowing of the portal through which the spinal nerve passes from the spinal column, out of the spinal canal to the body), spondylolisthesis (slippage of one vertebra relative to another), and spinal stenosis (compression of the nerve roots or spinal cord by bony spurs or other soft tissues in the spinal canal). Spinal-nerve compression in these conditions can lead to sciatica pain that radiates down the lower extremities. Spinal stenosis can cause lower-extremity pains that worsen with walking and are relieved by resting (mimicking poor circulation).

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BONY AND JOINT CONDITIONS Bone and joint conditions that lead to low back pain include those existing from birth (congenital), those that result from wear and tear (degenerative) or injury, and those that are from inflammation of the joints (arthritis). Congenital bone conditions —Congenital causes (existing from birth) of low back pain include scoliosis and spina bifida. Scoliosis is a sideways (lateral) curvature of the spine that can be caused when one lower extremity is shorter than the other (functional scoliosis) or because of an abnormal design of the spine (structural scoliosis).

Spina bifida is a birth defect in the bony vertebral arch over the spinal canal, often with absence of the spinous process. This birth defect most commonly affects the lowest lumbar vertebra and the top of the sacrum. Occasionally, there are abnormal tufts of hair on the skin of the involved area. Spina bifida can be a minor bony abnormality without symptoms. However, the condition can also be accompanied by serious nervous abnormalities of the lower extremities. Degenerative bone and joint conditions —As we age, the water and protein content of the body's cartilage changes. This change results in weaker, thinner, and more fragile cartilage. Because both the discs and the joints that stack the vertebrae (facet joints) are partly composed of cartilage, these areas are subject to wear and tear over time (degenerative changes). Degeneration of the disc is called spondylosis. Spondylosis can be noted on x-rays of the spine as a narrowing of the normal "disc space" between the vertebrae. It is the deterioration of the disc tissue that predisposes the disc to herniation and localized lumbar pain ("lumbago") in older patients. Degenerative arthritis (osteoarthritis) of the facet joints is also a cause of localized lumbar pain that can be detected with plain x-ray testing. Injury to the bones and joints—Fractures (breakage of bone) of the lumbar spine and sacrum bone most commonly affect elderly people with osteoporosis, especially those who have taken long-term cortisone medication. For these individuals, occasionally even minimal stresses on the spine (such as bending to tie shoes) can lead to bone fracture. In this setting, the vertebra can collapse (vertebral compression fracture). The fracture causes an immediate onset of severe localized pain that can radiate around the waist in a band-like fashion and is made intensely worse with body motions. This pain generally does not radiate down the lower extremities. Arthritis —the spondyloarthropathies are inflammatory types of arthritis that can affect the lower back and sacroiliac joints. Examples of spondyloarthropathies include reactive arthritis (Reiter's disease), ankylosing spondylitis, psoriatic arthritis, and the arthritis of inflammatory bowel disease. Each of these diseases can lead to low back pain and stiffness, which is typically worse in the morning. These conditions usually begin in the second and third decades of life.

OTHER CAUSES OF LOW BACK PAIN

KIDNEY PROBLEMS Kidney infections, stones and traumatic bleeding of the kidney (hematoma) are frequently associated with low back pain. PREGNANCY Pregnancy commonly leads to low back pain by mechanically stressing the lumbar spine (changing the normal lumbar curvature) and by the positioning of the baby inside of the abdomen. Additionally, the effects of the female hormone estrogen and the ligament-loosening hormone relaxin may contribute to loosening of the ligaments and structures of the back. OVARY PROBLEMS Ovarian cysts, uterine fibroids and endometriosis infrequently causes low back pain. •

TUMOR

Low back pain can be caused by tumors, either benign or malignant, that originate in the bone of the spine or pelvis and spinal cord (primary tumors) and those which originate elsewhere and spread to these areas (metastasize). Symptoms range from localized pain to radiating severe pain and loss of nerve and muscle function (even incontinence of urine and stool) depending on whether or not the tumors affect the nervous tissues.

Uncommon causes of low back pain Paget’s disease of bone Bleeding or infection in the pelvis Infection of the cartilage and/or bone of spine Aneurysm of the aorta Shingles (Herpes Zoster)

ASSESSMENT OF A PATIENT WITH LOW BACK PAIN

DEMOGRAPHIC DATA Name, age, gender, occupation, socio economic status Complaints - patient complaints of pain in the lower back or gluteal region. HISTORY • • •

Past history- h/o DM or HTN Family history-h/o DM or HTN Present history-cause of pain, onset of pain, duration of pain Red Flags for Acute Low Back Pain History Cancer Unexplained weight loss Immunosuppression Prolonged use of steroids Intravenous drug use Urinary tract infection Pain that is increased or unrelieved by rest Fever Significant trauma related to age (e.g., fall from a height or motor vehicle accident in a young patient, minor fall or heavy lifting in a potentially osteoporotic or older patient or a person with possible osteoporosis) Bladder or bowel incontinence Urinary retention (with overflow incontinence) Physical examination Saddle anesthesia Loss of anal sphincter tone Major motor weakness in lower extremities Fever Vertebral tenderness Limited spinal range of motion Neurologic findings persisting beyond one month

OBSERVATION

Build of the patient- Endomorphic/ectomorphic / mesomorphic Gait and Posture- Observation of the patient's walk and overall posture is suggested for all patients with low back pain. Scoliosis may be functional and may indicate underlying muscle spasm or neurogenic involvement. Range of Motion- The examiner should record the patient's forward flexion, extension, lateral flexion and lateral rotation of the upper torso. Pain with forward flexion is the most common response and usually reflects mechanical causes. If pain is induced by back extension, spinal stenosis should be considered. External appliances - use of external aids like cane, crutch, walker, brace etc. Attitude of the limbs PALPATION/ PERCUSSION Point tenderness over the spine with palpation or percussion may indicate fracture or an infection involving the spine. Palpating the paraspinous region may help delineate tender areas or muscle spasm. Tenderness over the sciatic notch with radiation to the leg often indicates irritation of the sciatic nerve or nerve roots. TEST AND EXAMINATION Heel-Toe Walk and Squat and Rise- A patient unable to walk heel to toe, and squat and rise may have severe cauda equina syndrome or neurologic compromise. Straight Leg Raising Test(SLR)- With the patient in the supine position, each leg is raised separately until pain occurs. The angle between the bed and the leg should be recorded. Pain occurring when the angle is between 30 and 60 degrees is a provocative sign of nerve root irritation. Crossed SLR Test- The contralateral, uninvolved leg is raised. The test result is positive when pain is produced. This test is less sensitive but much more specific for disc herniation. Popliteal Compression Test- Bending the knee while maintaining hip flexion should relieve the pain, and pressure in the popliteal region should worsen it. Lasegue’s Sign- If placing the knee back in full extension during straight leg raising and dorsiflexing the ankle also increase the pain (Lasègue's sign), nerve root and sciatic nerve irritation is likely.

Reflexes and Motor and Sensory Testing

 Testing knee and ankle reflexes in patients with radicular symptoms often helps determine the level of spinal cord compromise.  Weakness with dorsiflexion of the great toes and ankle may indicate L5 and some L4 root dysfunction.  Sensory testing of the medial (L4), dorsal (L5) and lateral (S1) aspects of the foot may also detect nerve root dysfunction.

LABORATORY TESTING They are generally not necessary for initial evaluation of acute low back pain. Complete Blood Cell Count and ESR- If tumour and infection suspected. HLA-B27 antigen test- If Ankylosing Spondylitis suspected. Serum Protein Electrophoresis- If multiple myeloma suspected. Urine analysis

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RADIOGRAPHIC TESTING X-RAY Selective Indications for Radiography in Acute Low Back Pain Age >50 years

Drug or alcohol abuse History of cancer Significant trauma Use of corticosteroids Neuromotor deficits Temperature >=37.8°C Unexplained weight loss (10 (100.0°F) lb in six months) Recent visit (within 1 month) Suspicion of ankylosing for same problem and no spondylitis improvement Patient seeking compensation for back pain CT SCAN,MRI AND MYELOGRAPHY If red flags suggest cauda equina syndrome or progressive major motor weakness, the prompt use of computed tomography (CT), magnetic resonance imaging, myelography or combined CT and myelography is recommended. In the absence of red flags after one month of symptoms, it is reasonable to obtain an imaging study if surgery is being considered.

MANAGEMENT OF PATIENTS WITH LOW BACK PAIN

Most patients require only symptomatic treatment for acute low back pain. In fact, about 60 percent of patients with low back pain report improvement in seven days with conservative therapy, and most note improvement within four weeks. CONSERVATIVE MANAGEMENT Patients should be instructed to watch for worsening symptoms such as an increasing loss of motor or sensory functions, increasing pain and the loss of bladder or bowel function. Should any of these occur, the patient should undergo further evaluation and treatment immediately, with weekly followup. Patients should gradually return to their normal activities, as tolerated. Continuing ordinary activities within the limits permitted by pain leads to a more rapid recovery than either bed rest or back-mobilizing exercises. •

Bed rest Medications-NSAIDS (to relief pain), Muscle Relaxants (to relief spasm) Patient’s education Psychological support to the patient is required if patient is under stress (stress

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SURGICAL MANAGEMENT Surgery maybe necessary if back pain is severe n depending on the cause of pain. Some of the surgeries done are- surgical decompression, laminectomy, dissectomy, vertebroplasty etc.

PHYSIOTHERAPY MANAGEMENT FOR LOW BACK PAIN PAIN RELIEF

Physiotherapy of different types can be used to treat lower back pain.

Acupuncture is fast becoming an important method for the relief of such pain. The patient lies face-down and inserts the acupuncture needles across the back. Pain relief after a series of treatments usually lasts months. − Back massage is also used for lower back pain. − Modalities are also used to treat back pain. They are:−

 Heat and Cold Packs- they can be used separately or together alternately to relief acute low back pain. Heat therapy induces vasodilatation drawing blood into the target tissues. Increased blood flow delivers needed oxygen and nutrients, and removes cell wastes. The warmth decreases muscle spasm, relaxes tense muscles, relieves pain, and can increase range of motion. Cold therapy produces vasoconstriction, which slows circulation reducing inflammation, muscle spasm, and pain.

Transcutaneous Electrical Nerve Stimulator (TENS)- TENS units deliver electrical stimulation to the underlying nerves via electrodes placed over the intact skin surface near the source of maximal pain. 

Ultrasound Therapy- It delivers heat deep into the muscles of the lower back. This not only relieves pain. It can also speed healing.  Iontophoresis- Iontophoresis is a means of delivering steroids through the skin. The steroid is applied to the skin and then an electrical current is applied that causes it to migrate under the skin. The steroids then produce an anti-inflammatory effect in the general area that is causing pain. This modality is especially effective in relieving acute episodes of pain.  Trigger Point Release (TPR) -Trigger points or trigger sites are described as hyperirritable spots in skeletal muscles that are associated with palpable nodules in taut bands of muscle fibres. Releasing of these points can be done by ischaemic compression of the point, friction massage or stretching. Hence helps to decrease pain and release muscle spasm.  Myofascial Release- It is a form of soft tissue therapy used to treat somatic dysfunction and accompanying pain and restriction of movements. This is accomplished by relaxing contracted muscles, increasing circulation, increasing venous and lymphatic drainage, and stimulating the stretch reflex of muscles and overlying fascia. 

LOW BACK EXERCISE PROGRAM The low back exercise program is a series of stretching exercises and strengthening exercises. The purpose of this exercise program is to improve the flexibility and strength of trunk musculatures essential for low back care. 1. KNEE TO CHEST Starting Position: Lie on your back on a table or firm surface. Action: Clasp your hands behind the thigh and pull it towards your chest. Keep the opposite leg flat on the surface of the table Maintain the position for 30 seconds. Switch legs and repeat. Do Not Cause Pain. 2. PELVIC TILT Starting Position: Lie on your back on a table or firm surface. Your feet are flat on the surface and the knees are bent. Action: Push the small of your back into the floor by pulling the lower abdominal muscles up and in. Hold your back flat while breathing easily in and out. Hold for five seconds. Do not hold breath. Do Not Cause Pain. 3. HIP ROLLING Starting Position: Lie on your back on a table or firm surface. Both knees bent, feet flat on the table. Action: Cross your arms over your chest. Turn your head (trunk) to the right as you turn both knees to the left. Allow your knees to relax and go down without forcing. Bring knees back up, head to centre. reverse directions. Do Not Cause Pain. 4. PELVIC LIFT Starting Position: Lie on your back on a table or flat surface. Your feet are flat on the surface and your knees are bent. Keep your legs together Cross your arms over your chest.

Action: Tilt your pelvis and push your low back to the floor as in the previous exercise, then slowly lift your buttocks off the floor as far as possible without straining. Maintain this position for 5 seconds. Lower your buttocks to the floor. Do not hold breath. Do Not Cause Pain. 5. LOWER ABDOMINAL EXERCISES Starting Position: Lie on your back on a table or firm surface. Knees bent flat on the table. Flatten your back to the floor by pulling your abdominal up and in. Action: A. Bring one knee toward your chest. Hold this position for ____ Lower your leg to the starting position. Then repeat on your opposite knee.

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B. Bring one knee toward your chest. Straighten the knee Hold for ____ seconds. Slowly lower the leg to the starting position. Repeat on opposite leg. C. Raise your leg keeping your knee straight. Hold for ____ seconds. Slowly lower the leg to the floor.Repeat on the opposite leg. Maintain your pelvic tilt and keep your resting leg relaxed at all times. Do not hold your breath. Do Not Cause Pain. 6. CURL UPS Starting Position: Lie on your back on a table or flat surface. Your feet are flat on the surface and your knees are bent. Maintain your pelvic tilt for the curl up exercises. Action: A. Slowly reach your arms in front of you as much as possible, curling your trunk. Slowly keep the neck muscles relaxed. Breathe normally. Slowly return to the starting position. Do Not Cause Pain. B. Fold your arms on your chest. Tuck your chin to your chest and slowly your elbows to your knees, curling your trunk. Keep neck muscles relaxed breathe normally.Return to the starting position. C. With your hands behind your head, slowly curl your head to your chest your trunk. Relax, breathe and then slowly return to the starting position. Do Cause Pain. 7. CAT AND CAMEL Starting Position: Kneel down on the floor and assume the "all-four's" position. Keep your head straight so that the gaze of your eyes is toward the floor. Action: Slowly allow your trunk to sag as far as you can so that your back is arched Do no, pull it down. but let it relax as you lift up your face towards the ceiling Then round your back up at the waist as far as you can by contracting your lower abdominal muscles as you lower the top of your head toward the floor. All motion should be initiated from your low back. Do Not Cause Pain. 8. TAIL WAGGING Starting Position: Kneel on a mat and assume the "all-four's" position Keep head in a neutral position by looking down at the floor. Action: Keeping your shoulders still, move your right hip toward your right shoulder as far as you can. Slowly return to the starting position then move your toward your left shoulder as far as you can. Do Not Cause Pain.

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9. HIP EXTENSION Starting Position: Assume the "all-four's" position. Action: Bring one knee toward your head as you lower the head. Extend the and the leg out to a flat position parallel to the floor Return to the starting position. alternating legs. Do Not Cause Pain. 10. HAND KNEE ROCKING Starting Position: Kneel on a mat with your knees and ankles. Allow your buttocks on your heels. Action: Take your upper body over so you are in a crouched position with your arms out in front of you. Relax in this position and then slowly move forward with your straight into a press-up position. Do Not Cause Pain.

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11. LYING PRONE IN EXTENSION Starting Position: Lie on your stomach on a mat with your weight on your forearms. Action: Lie on your stomach on a mat and lean on your elbows Stay in this position for about _____, making sure that you relax your low back completely. Do Not Cause Pain 12. PRESS UP Starting Position: Lie on your stomach on a mat. Place your hands palms down, under your shoulders. Action: Straighten your arms, raising your upper trunk off the floor. Keep your pelvis against the mat, allowing your lower back to arch. Hold for ____ seconds. Return to starting position and repeat. Do Not Cause Pain. 13. BACK EXTENSION Starting Position: Lie on your stomach on a mat. Place your arms at your sides so that your hands are by your hips. Action: Raise your head and shoulders off the mat as high as comfortably possible. Hold for ____ seconds. Lower the head and shoulders. Do not tense your shoulder muscles. Do Not Cause Pain. 14. ARM LIFTS Starting Position: Lie on your stomach on a mat. Stretch your arms head and slightly out to the side (in a V position). Action: Lift one arm, with your hand positioned so that the thumb points upward. Keep your thighs and your opposite arm relaxed. Slowly lower your arm, then raise the other arm in the same manner. Do Not Cause Pain. 15. KNEE PUSH UP Starting Position: Lie on your stomach on a mat. Place your hands, palms down, on the mat at the level of your shoulders. Pushing with your arms, lift your trunk and thighs off the surface of the mat until your elbows are straight. Your knees should be bent, and your lower legs and feet should be on the mat. Keep your back straight and do not let your stomach sag. Action: Slowly bend your elbows, lowering your trunk and thighs toward the surface of the mat. Push away from the mat again, straightening your arms. Do Not Cause Pain.

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16. PUSH UP Starting Position: Lying on your stomach, place your hands, palms down, on the floor at the level of your shoulders. Flex your toes so that the weight of your body is shared by your hands and soles of your feet. Pushing with your arms raise your trunk and legs off the floor. Keep your back straight and do not let your stomach sag. Action: Bend your elbows to lower your body halfway toward the floor then push your body back by straightening your arms. Do Not Cause Pain. 17. FULL BACK RELEASE Starting Position: Sit in a chair with your feet flat. Relax your shoulders and keep your head level. Your weight should be evenly distributed between your buttocks and your feet. Action: Relax your neck. Curl your neck, upper back and low back slowly forward. Allow your hands to reach the floor so your palms are touching the floor. Hold for ____ seconds. Straighten up slowly so that you bring your head up last. Return to the starting position. Do Not Cause Pain. 18. UPPER BACK STRETCH Starting Position: Sit on a stool with your back flat against a wall. Action: Lift your arms overhead, keeping your head and back flat against the wall. Hold for ____ seconds. See if your shoulders can touch the wall while keeping your back flat, Hold for ____ seconds. Lower your hands to the starting position. Do Not Cause Pain. 19. SIDE BENDING Starting Position: Stand up straight with your arms at your sides and your feet shoulder width apart. Action: Bend your trunk to one side, by lowering your shoulder Run your hand down the outside of your thigh. Hold for seconds. Slowly straighten up. Repeat to the opposite side. Do Not Cause Pain. 20. BACKWARD BENDING Starting Position: Stand up straight with your feet shoulder width apart. Keep your knees as straight as possible. Place your hands on your back firmly at your waist level. Action: Bend backwards at your waist keeping the knees as straight as possible. Hold ____ seconds. Return slowly to the upright position. Do Not Cause Pain.

21. PECTORALIS STRETCH Starting Position: Stand with your legs together facing a corner. Extend your arms and place your palms against the opposite walls of the corner. Action: Lean toward the corner. Keep your body and legs straight and your heels firmly on the floor. Hold for ____ seconds. Return to the starting position. Repeat gradually increasing your distance from the corner. Do Not Cause Pain. CORE BODY STRENGTHENING

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This is done by using exercise ball or Swiss ball as followFront walkout - Place chest on exercise ball and walk forward on hands as far as possible, rolling exercise ball from chest toward feet, keeping stomach muscles tight to keep lower back flat. Start by moving exercise ball to thighs; to increase difficulty move exercise ball to knees then feet. Walk hands back to starting position. Repeat 3 to 5 times. •

Back walk-out - Sit on exercise ball with arms to sides; walk feet forward as far as possible, rolling exercise ball from buttocks toward neck, keeping stomach muscles tight to keep lower back flat and do not raise head. Start by moving exercise ball to upper back; to increase difficulty move exercise ball to neck. Walk feet back and return to sitting position. Repeat 3 to 5 times. For more difficulty, complete exercise with arms straight overhead; with exercise ball at neck, lift and straighten one leg at a time, 5 times each leg. •

• Reverse crunch - Place chest on exercise ball and walk forward on hands until ball is at kneecaps, keeping stomach muscles tight to keep lower back flat. Pull the ball up towards arms by bending at hips and knees, then straighten and push the ball back. Repeat 5 times. Walk hands back to starting position. Reverse extension - Place chest on exercise ball and walk forward on hands until exercise ball is at kneecaps, keeping stomach muscles tight to keep lower back flat. Roll the ball to thighs by keeping hands in place, moving arms to an overhead position, bringing head and chest down near floor; return arms to perpendicular to body with exercise ball back at knee caps. Repeat 5 times. Walk hands back to starting position. •

• Combination - Complete the reverse crunch and reverse extension in one continuous, controlled movement, pulling exercise ball up to chest and extending back 5 times.

ABDOMINAL EXERCISES WITH THE EXERCISE BALL Half crunch - Sit on exercise ball with arms raised across chest or on hips; lean back half way, flexing at hips without moving feet but raising up on toes; use abdominal muscles to sit up without moving feet but rocking back on heels. Rock back and forth on the ball smoothly 5 times. Increase difficulty with arms straight overhead •

Obliques - Sit on exercise ball with arms raised straight overhead; lean back half way, flexing at hips without moving feet but raising up on toes; lower one arm at a time slowly towards the opposite knee. Alternate arms 10 times each side. •

Full crunch - Sit on exercise ball with arms at sides and feet flat on floor and out in front, sitting slightly forward on ball; lean back all the way, rolling ball to the low back then mid-back; keeping feet flat on the floor, use abdominal muscles to sit up. Repeat 5 times. •

AEROBIC EXERCISES Aerobic exercises such as walking are excellent for reducing and preventing lower back pain as well. SPINAL SUPPORTS

ERGONOMIC ADVICES • Keeping active as much as possible and continuing with routine everyday activities such as going to work, will hasten recovery from lower back pain. Limiting movement and doing a little exercise will only increase the risk of developing chronic symptoms. • Watch posture-sitting, walking, standing, lifting. • Resume activities step by step. HOME EXERCISE PROGRAMME The patient has to continue the exercise programme at home once/twice a day. Maintain fitness by doing activities.

PROPER WALKING

PROPER SITTING

Bibliography- Tidy’s physiotherapy - Internet

PROPER STANDING

PROPER LIFTING TECHNIQUE