Fixing You: Back Pain 2nd Edition is Here!

Wow, I can’t believe I’ve finally completed the 2nd edition of Fixing You: Back Pain! I’ve been working on it for 2 years now and there are so many changes, I wanted to devote a blog entry to talk about them.

Fixing You: Back Pain 2nd Edition will be offered at half-price, only $10, for a limited time as a thank you to my previous readers.

1. If you’re familiar with the 1st edition, I think the first big change is a departure from the category of Rotation Problems in favor of Sidebending Problems. “What’s the big deal?” Fig12_Sidebendingyou might ask. Well it’s a very big deal because I believe the sidebending issues are creating the rotation problems. It kind of works like this, when the spine is in a neutral position, sidebending to one side creates rotation to the opposite direction. So if the spine is sidebending to the left, it rotates to the right. The first edition of Fixing You: Back Pain identified these issues as rotation problems however it’s very difficult to correct a rotation issue. Now I believe that is because the driver of the rotation problem is actually a sidebending problem. And these are much easier to fix as you’ll see in the second edition. I think the sidebending issues are the main culprits in creating unilateral back pain or sciatic pain. This has been a significant tool in the correction of asymmetry in the pelvis and lumbar spine.

2.These past few years I’ve looked more into fascia and have included more information about the role of fascia in chronic pain. I’ve uncovered some research that connects fascial contraction to our sympathetic nervous system response (our fight-or-flight or stress response). I’ve completely re-written the first section, Mindful Healing, to include how our brain, stress, fascia, and habits come together to create chronic contraction patterns. I think you’ll find it interesting and useful. To this end, I’ve included a worksheet in the Appendix of the book to help you identify and quantify stress in your life. This can go a long way to relieving chronic pain due to the connection between the stress and fascial contraction.

3. Hanna Somatics techniques have been introduced. I have spent 3 years studying Hanna Somatics, which has become a very important approach in my clinic when working with chronic pain patients or those with recurring injuries. I’ve “somaticized” some of my exercises to reflect this learning. I’ve also created separate audio and video somatics lessons to help people reduce tension and pain throughout their bodies. These can be found at www.FixingYouBooks.com.

4. Re-shot all videos of exercises and tests in the book! There are now many more exercises as well as tests in this book to help you more precisely understand and fix your pain. The videos look great, offering more detail, and I think they will be VERY helpful in taking your solutions to the next level.

5. Lots more images! There are over 145 pictures and images in this book (69 in the first 2 sections and 76 in the 3rd section of corrective exercises) as compared to the 1st edition which had 58 (23 in the first 2 sections and 35 in the 3rd section of corrective exercises). Part of the reason this revision has taken so long is waiting for the new images and figuring out how to fit them into the book. I actually had to go to an 8×10 layout, which I think you’ll find easier to read.

6. I have more recommendations about how to change sitting, standing, walking and bending habits that seem to be at the root of a lot of people’s pain. Overall the 2nd edition is now 177 pages while the first edition was only 123. This is such as substantial increase in size, I have to list it as a completely new book!

7. Read a chapter for free! I’m offering Chapter 3: The Basics free if you’d like to check it out first or send it to a friend who might need some help. This chapter talks about things that happen in the background that set us up for back pain. I think you’ll find it useful.

I hope Fixing You: Back Pain 2nd edition helps even more of you fix your pain. Thank you all for your patience and support as I put this together. Please feel free to leave a review on Amazon as I must start all over again with the reviews since this is considered a new book. Thank you and let me hear your stories!

Patient Story: From Wheelchair to Pain Free in 5 Visits

I recently saw a woman who had such crippling back and sciatic pain that she had to use a wheelchair to go to church and couldn’t stand. This was building for several months and she finally sought help.

Fig12_Sidebending

Muscle imbalances in the legs can feed issues up above.

What I found during our exam was one side of the pelvis higher than the other, contracted hip flexor muscles, one side of her rib cage was lower than the other, a walking pattern that promoted hyperextending knees and a very strong heel strike, a thigh bone that rotated in too far at foot strike, two flat feet and ankles that collapsed too. She was kind of like the picture to the right– her body was all askew. She was very tense so that when I touched or moved her, she jumped or couldn’t allow me to really move her passively.

She was very scared because her quality of life had diminished significantly and she was on the verge of tears. Her work involved a large amount of stress and she just seemed to absorb it right into her body. She was a very caring person but took on too much of other peoples’ concerns. She doubted she could ever return to her old life.

After 5 visits she was a completely different woman. No wheelchair, she smiled more and was more relaxed while walking. She could bend down to the floor without any pain and could sit or stand for long periods of time with no pain at all. In summary, she was the picture of health and confidence with no pain whatsoever.

How did she do it? As with all our patients at the clinic, we focus on decreasing tension and improving how people do things like sitting, standing, walking etc. She had downloaded my audio Somatics Movement Lessons (Hanna Somatics) and practiced those every day which began to unlock her body. There are 8 gentle lessons in this audio download, targeting different parts of the body.

The material in this audio download includes:

Lesson 1: Back Movements (approximately 35 minutes)

Lesson 2: Front Movements (approximately 30 minutes)

Lesson 3: Waist Movements (approximately 26 minutes)

Lesson 4: Rotation Movements (approximately 25 minutes)

Lesson 5: Hip Movements (approximately 27 minutes)

Lesson 6: Neck Movements (approximately 50 minutes)

Lesson 7: Breathing (approximately 27 minutes)

Lesson 8: Walking (approximately 32 minutes)

 

As a bonus, they help decrease the sympathetic nervous system level while increasing the level of the parasympathetic nervous system–great when you want to reduce the effects of stress on your body!

In the clinic I used similar techniques to more specifically release patterns of contraction in her body. We combined this with a better way of walking, sitting, and bending over. You can see an example of this in my post: I Don’t like Doing My Physical Therapy Exercises!. In addition, I merely told her she’s carrying too much stress from her work and she needed to distance herself from it and protect herself.

I think the moral of the story is no matter how bad it may seem, trust that there is a solution to your pain. You must keep trying–there is an answer!

Many of these issues are addressed in my book Fixing You: Back Pain (2nd ed) available on Amazon soon.

I Don’t Like Doing My Physical Therapy Exercises!

I just got off the phone with a friend of mine whose husband is having back pain. She said, “When he does his exercises, he feels great. When he doesn’t, he doesn’t”. This brings up a big beef for people seeing a physical therapist–they don’t want to do exercises for the rest of their life to keep their pain at bay. I don’t blame them.

I heard from one of my other patients that a PT told him long ago that only 30% of their patients get better because people don’t do their exercises. Only 30%! That’s crazy!

Gosh, why are so many people not doing their exercises? Well first of all, I don’t know –I rarely hear this complaint at my clinic. But I have an idea. I think the problem is that the exercises most people receive don’t meaningfully apply to their lives. They’re probably exercises that people have to stop to do in a special place and require a lot of time time to do them. “We’re busy, we don’t have time for exercises!” is what many of you are probably thinking. Rightfully so.

So why don’t I run into this problem at my clinic? Well I think it’s because I focus on pain-causing movements rather than weak or tight muscles. We identify the movements that are painful, understand the muscular issues and/or biomechanics behind the problem and integrate those fixes back into a better way of doing things. So what I recommend to people is more about improving how they do things like walking, bending, sitting, and sleeping. That way the changes are part of their lifestyles and require little to no extra time out of their days to do them. They just require some attention and thoughtfulness.

The video below shows what I’m talking about. If I’ve determined someone’s butt muscles are weak or not participating enough, I can teach them to integrate those muscles into activities like stair climbing. This is especially helpful if they’re complaining about knee, hip, or back pain when climbing stairs! Check it out, this is one of the videos from my revised back pain book due out soon (I hope!).

 

This is also why most of my patients’ pain doesn’t return, because they’ve fixed the behaviors that caused it in the first place. There’s a lot of education that goes on in my clinic and by the time my patients leave, they know exactly why they have pain, exactly what to do to correct it, and how to apply those behaviors to new activities. I want them to understand their bodies and brains just as well as I do. That way they don’t need to see me once a month or even once a year. They can just fix themselves! Isn’t that what it’s all about?

 

Jason Dufner’s Neck Pain

Jason Dufner, a big golf fan favorite, had to pull out of the PGA Championship this year due to neck pain. It appears he has a couple of bulging discs. Apparently he’s tried everything but hasn’t seen any relief. So what could be the cause of Jason’s disc bulges and neck pain?

Figure 1. Scapular muscles

Figure 1. Scapular muscles

Well to lay a little groundwork, the neck region is unique in the body in that it’s strongly influenced by a system that doesn’t really have a bony attachment to it. What I mean by this is that everywhere else in the body, bones stack on top of bones which help those bones stay in alignment. The neck, however, is a little different. While it’s true the neck bones (cervical vertebrae) stack on top of each other, there is a major player affecting it that doesn’t even attach to it from a bony standpoint–the shoulder.

The shoulder girdle (including the collarbone and shoulder blade) are kind of a floating system on the upper body. Unlike every other movement system, this one is held in place almost exclusively by muscles. Two of those muscles, the levator scapula and the trapezius, attach directly to the head and neck (Figure 1).

The levator scapula is deep to the trapezius and much smaller. It runs from the shoulder blade up to the first four neck bones. Its job is to help elevate the scapula–just like its name implies. The trapezius runs from the shoulder blade and collarbone to the base of the skull and all the vertebrae down to about the low back area. It’s one of the prime movers and stabilizers of the shoulder blade.

Unfortunately there are some other big gorillas that mess with the shoulder girdle to throw it off. When this happens, stress is delivered to the neck and head creating excessive force and contributing to neck pain, headaches, disc bulges, strange head and face symptoms, as well as arm symptoms. About 99% of the neck pain and headaches I treat in the clinic are due to shoulder girdle dysfunction–regardless of whether there are bulges or degenerated discs, facet issues or other types of structural diagnoses. I write about these issues in my neck pain book.

If you think about it, this makes sense because what else could be straining the neck so much? Yes the head weighs about 12-15 pounds but Jason’s a young guy and with plenty of strength and good enough posture to hold his head in a relatively proper position. There really aren’t any other stressors.

Now think about the golf swing. It involves big arm and shoulder movements and the arm is given even more leverage against the neck by adding a long club moving at tremendous speeds (about 100-150 mph for pros). Given these loads, doesn’t it make sense that the levator scapula and trapezius muscles are wreaking havoc on Jason’s neck?

If I were to have an opportunity to help The Duf, I would begin with the shoulder girdle system, fixing the issues creating movement dysfunction. Once these are corrected, only then would I begin working with his neck directly. Otherwise those big arms and shoulders would just keep delivering their destruction. Good luck, Jason! Read my book or shoot me an email and I’d be happy to help!

Missy Franklin’s Back Pain

I’m so sorry to hear of Missy Franklin’s struggles with back pain. She’s a great person, athlete, and has inspired millions with her incredible skill at the 2012 Olympics. But swimming is normally an exercise that people are given to cure back pain not create it. So what could be the problem?

Well it’s important to understand that the site of most pain is like a crime scene. The painful joints or tissues are the victims while the culprits lurk outside the crime scene tape in the shadows. With regards to back pain, most pain is due to a problem with excessive arching of the spine. I call this an extension problem in my back pain book. Arching the spine creates compression of the discs and facet joints and, after repeated arching, the back muscles begin to accommodate this by remaining contracted as that’s what they’ve learned to do.

Figure 1. Pelvic Muscles Contribute to Back Pain

Figure 1. Pelvic Muscles Contribute to Back Pain

The culprits in this crime scene can be found in a few places. Some of them are the hip flexors which attach from the front of the pelvis to below the knee. When they are tight or overly contracted, they contribute to forward (anterior) tilting of the pelvis. The lower spine, being attached to the pelvis at the sacrum and being very good at arching (see graphic in Tiger Woods’ Back Pain), is then forced to arch to accommodate this pelvic position. Repeat this a few million times, as is the case while walking (or kicking of a swimmer’s legs) and disc degeneration, disc bulges, disc herniations, or facet issues ensue (Figure 1).

Another stressor creating an extension problem is tightness of the latissimus dorsi muscle. This muscle is very large and begins at the pelvis and lumbar spine running up to the shoulder blade and finally inserting onto the upper arm bone. If it’s tight or contracted, the back will arch to allow the arm to reach. Most people aren’t aware this is even happening. So when the arm is reaching overhead as in a shoulder press (or in swimming during any of the strokes) the back arches a little delivering more extension stress to the spine.

A third stressor is poor rear-end muscle, or gluteal, motor control (being able to control the turning on or off of a muscle). When the gluteal muscles aren’t being used well when bringing the leg back, others must make up for their slack. Usually these are the hamstrings and low back muscles. This very frequently comes into play with poor walking habits or, in the case of swimmers, poor kicking habits.

Lastly poor core (and specifically the external oblique muscles) control allows the spine to arch excessively. These muscles help guard against excessive extension of the low back. You can do a thousand sit-ups a day and still have weak external obliques though if you’re not specifically training them. And even if they are strong, they can’t offset the first three problems due to the leverage the arms and legs have over the core in acting on the spine.

So these would be the first places I’d look if I were to help Missy. I sure hope she recovers.

I’ve Tried Physical Therapy Before…

Yesterday I overheard a woman say to a friend that she had tried physical therapy before and it didn’t help so she’s looking for other alternatives. I think this comment highlights the thinking that there is only one type of solution that a physical therapist can offer.

There are many types of treatments available to help people: physical therapy, chiropractic, acupuncture, surgery, massage, Pilates and countless others. All of these approaches have helped people in the past, that’s why they’re around today. And within each discipline there are many approaches to correcting a problem. For instance in physical therapy we use biomechanical approaches, neuromuscular re-education, sympathetic nervous system reduction, various types of massage, therapeutic dry needling (using acupuncture needles), joint mobilizations/manipulations, therapeutic exercise, electrical stimulation just to name a few. There are myriad approaches within physical therapy as we can draw from a large spectrum of knowledge. So to have gone to one practitioner, who may only have knowledge of a certain type of approach, or limited experience with your type of problem, does not mean physical therapy has failed, just that the practitioner didn’t offer the tools to help with your particular problem. It’s like going to a restaurant and not being happy with your meal and coming to the conclusion that restaurants don’t serve good food.

At Body in Balance Physical Therapy, we help just about every patient who comes in, no matter where their pain is in the body or whether it’s due to auto accidents, sports injuries, chronic pain, workplace injuries, post-surgical issues or others. The reason we’re successful with such a wide range of issues is that we understand that the body works as a system of movement. For instance wrist pain is not only due to a problem in the wrist. It potentially involves the fingers, wrist, elbow, shoulder, scapula, neck, and even the pelvis and rib cage. Each of the therapists in our clinic evaluate an entire spectrum of potential issues creating stress to the wrist so we are more likely to find answers to difficult questions about pain. Many of these connections are highlighted in my Fixing You series of self help books for pain, sold on Amazon. I like to think of ourselves as systems analysts for the human body!

So if you’ve tried physical therapy before and it hasn’t helped, keep trying because, like many things in life, we’re all different. I firmly believe in our body’s ability to heal from just about anything. Whatever you do, don’t give up!

Tiger Woods’ Back Pain

Tiger Woods has been in the news a lot lately, although not for the reasons he’d prefer. Tiger’s struggles with back pain seem to be an on-again, off-again problem preventing him from competing at a level he’s capable of. I thought I’d chime in on some of my thoughts about what I think might be going on. Tiger if you read this give me a call, I think I can help!

First of all I think Tiger’s left knee issues are a factor. The left knee is important because it helps generate torque through the pelvis. This is achieved by snapping it backward during the follow-through portion of the swing, which helps whip the pelvis around and therefore generates rotational force for the swing (this may be why the knee needed surgery in the first place). Because of Tiger’s left knee issues, some of this power is lost which will force him to create it somewhere else. So I think it would be interesting to see how that knee is really doing and whether it’s capable of handling the stress he’s trying to generate.

The next issue is that golf, of course, is a rotational sport. Rotation in the spine is coupled with sidebending in the opposite direction. Because of this, golfers often develop pelvic and lumbar asymmetry. This is usually in the form of one side of the pelvis becoming higher than the other and the same side rib cage is lower. This would create a sidebending posture which then manifests as a rotation issue too. I’ve found that correcting rotational issues is very difficult however fixing its counterpart, sidebending  issues, is quite simple. So it would be interesting to see if Tiger has this pattern and if it corresponds to the direction of rotation he uses in his swing.

Screen Shot 2014-08-29 at 1.16.50 PM

Available motions in the spine. 1

A third issue is that different levels of  the spine flex, extend, sideband, and rotate to different degrees. The potential of any of these motions is inherent in the level of the spine as each vertebra is shaped slightly differently to accommodate different functions. You’ll notice in the chart to the side that the lumbar spine has very little available rotation in comparison to the rest of the spine. Yet many golfers stretching programs focus on lumbar rotation. It would be interesting to see how Tiger’s program emphasizes rotation. There are other areas of the body that could be tapped to contribute to overall rotation, thus unloading the lumbar spine.

Lastly over the years Tiger has bulked up quite a bit. I assume this is to create more of a power game. But if you look at upcoming golfers in college and even high school, you’ll see lean athletes driving the ball just as far as many pros. To me this means the answer for Tiger is not in becoming stronger and bulkier, but instead becoming leaner and cleaner with his swing which would be based on his particular body mechanics.

I remember seeing an EMG study many years ago showing muscle activation patterns of pro versus amateur golfers. The pros’ muscles were generally more silent through most of the swing and then peaked at impact. This type of pattern creates very little stress to the body and is indicative of a fluid swing. The amateurs’ muscles were much more activated throughout the swing which creates more stress throughout the body and indicates a more forced swing. I don’t know if Tiger has any old EMG analyses of his swing when he was at the top of his game, but I would venture to say that perhaps now it is not as clean as it used to be. It may be that by bulking up, he is trying to rely on strength rather than working with his mechanics to create a less stressful swing.

Well that’s my two cents from someone who has never seen him. I sure would love to get a chance!

1. Clinical Biomechanics of the Spine. Panjabi, M., White, A..Lippincott Williams & Wilkins; Second edition (January 1, 1990).

New Addition to the Family

Just wanted to announce the arrival of Devra Reiman PT, DPT, the newest therapist at Body in Balance Physical Therapy. Devra graduated with a Doctorate of Physical Therapy degree from Ithaca College in May of 2013 so she’s up on the latest in clinical research in physical therapy. She’s also an accomplished tennis player with experience as a 4-year varsity player, senior captain, all-conference, and assistant coach at Ithica. In addition to weekdays, Devra will also be seeing patients every other Saturday.

You might see Devra getting physical during an ultimate frisbee game around town as she’s an avid player. Also she enjoys skiing, hiking, mountain biking, trail running,   meditation, and Sudoku puzzles. Overall a good fit for Colorado!

Devra has undergone extensive training at our clinic so she is also familiar with the unique Fixing You principles we use to help people get better. Between her and Lara, my other excellent therapist, I’m lucky to get any patients for myself! Please welcome her and say hello next time you’re in.

Devra Head

Devra Tennis

How to Create Good Habits

Whether you’re trying to shed a few pounds, get rid of an ache or pain, or be more successful, changing the way you currently do things can be tough. Why? Well it has to do with your brain. We have areas of our brain we use for every-day programs such as driving a car, grabbing a bite to eat, or how we feel about ourselves. These habitual programs are largely unconscious and therefore difficult to change.

Habits often involve a trigger, or cue, and a response to that cue. Most bad habits are actually responses to cues. For instance many people who have back or neck pain, feel it more when they drive. One of the reasons this happens is because driving (the cue) can be subtly stressful creating patterns of tension (the response) which then irritates the back or neck. Therefore driving becomes a trigger for pain-producing tension. You can sense this in yourself if, at a stop light, you pay attention to your low back and notice it’s tense and held in a little bit of an arch.

Because the way we drive (and our response to it) is largely unconscious, we must somehow become more aware of our stress response and change that to relax our body more. But how do we do that if driving is an unconscious act and we’ve got so many other things on our mind? Well you’ll need to set up reminders. A good reminder will help you become aware of your cues and create alternative, and hopefully healthier, responses to them. The best reminders are the one’s you’ll pay attention to.

do not forget reminder note on brain

For instance with my patients who have pain while driving I ask them to put a sticker, any old sticker, on the dashboard of their car. Every time they notice that sticker, they should take 4 deep breaths and think of something they’re deeply grateful for. This stimulates the parasympathetic nervous system (which can also be thought of as our rest-and-digest system) which reduces tension. If a sticker is out of the question then I ask them to do this at every stop light instead. So now the stop light becomes a cue for an alternative good habit.

This goes for any habit. First identify the habit that is giving you trouble. Then identify any cues which trigger that habit.  Develop a system where you begin recognizing the cues and then replace the bad habit with a good one. Reminders can be in any form; an alarm on your smart phone, wearing a special ring or bracelet, putting your watch on the opposite wrist–basically anything that you’ll pay attention to. I recommend taking on only one habit at a time. Make it an easy one in the beginning to build your confidence. Good luck and remember now is the best time to make changes and improve your life!

Swimming with Injuries

Have you noticed your neck, shoulder, or back hurting while swimming? You’re not alone! Aside from running injuries, swimming is right up there in terms of developing aches and pains. Why? Well let’s begin with back pain. When swimming, your spine is a bit arched or extended. The low back muscles contract to make this happen and this is normal. However you may be arching too much which causes pain. The reason this happens is typically the rear-end or gluteal muscles aren’t helping you kick. Instead the hamstrings and low back generate this movement. A very simple test is to lie on your stomach, reach back with your hands and place them on your rear-end. Now contract your rear-end muscles by pinching them together. Feel those muscles jump? Okay, now relax them and then lift your right leg as if kicking. Do you feel that right rear-end muscle contracting? How about the left? Most swimmers I see with back pain have the problem of not using their gluteals to kick. This creates extension stress at the back causing pain.

Still lying on your stomach, turn your head to the right and rest your left cheek on the back of your right hand with your right elbow bent out to the side resting on the floor. Your left arm should be down by your side. Now lift your head, right hand, elbow and shoulder as if looking over your right side. Is that easy or difficult? Now try it on the other side with the right arm down by your side. Notice whether it’s more difficult to rotate to one side than the other. This is often the case with swimmers. The problem, however, stems from one side of the waist muscles being too contracted creating what I call a sidebending problem (this will be featured in the upcoming revision of my back pain book due out in a couple of months, available on Amazon). A left sidebending problem creates a right-rotated spine. So rotating to the right becomes very easy. However rotating to the left becomes very difficult, because the spine is rotated to the right. Again this is driven by the left sidebending issues. This can also lead back pain but also neck and shoulder pain because the neck and shoulder must work harder to rotate and lift the left arm out of the water to swim.

Jane standing marked

The image above shows a person with a left sidebending problem. Note the crease on on left waist where there is none on the right. Her rib cage is depressed and the left side of the pelvis is elevated which creates this. If you look closely, you’ll notice the right side’s low back muscles are larger than the left side. Therefore her spine is rotated to the right. If she was swimming, it would therefore be easier for her to rotate to the right but more difficult to rotate to the left to breathe. This would contribute to back, neck, or even shoulder pain.

This is easily correctable and can result in a more efficient, pain-free swim stroke. Give us a call at Body in Balance Physical Therapy to set up an appointment to check you out, 303.477.5303. Have fun this summer!