Studies show that Americans suffer from back pain in significant numbers. It is a major contributor to absenteeism in the workplace; sixty to eighty percent of workers take time off because of it. Also, it is not exclusive to any one age group. The highest incidence of back pain occurs in those between the ages of 35 and 55, a worker’s prime years. Also, it is the leading cause of disability in people under 45. Clearly, back pain is pervasive.

Why is back pain so difficult to diagnose and treat? According to a classic study by Nachemson (1985), only 20% of those experiencing back pain can be given a specific patho-anatomical diagnosis, or, more simply put, only 20% can pinpoint a specific tissue such as disc herniation or muscle strain, to account for their back pain. For this reason, evaluation of back pain should include an analysis of how the individual’s body functions, not just an anatomical cause. For example, back pain is rarely the result of a single event or trauma, but rather repeated, inefficient movement and repetitive stress during daily activities.

At Thrive Physical Therapy, we examine how the body functions from a specific and global perspective, not only to determine what is painful, but also to identify–and correct–the underlying causes of the patient’s discomfort. Many factors contribute to back pain such as mobility, strength or weakness, body alignment/posture habits, efficiency of movement, work and daily activities. By using a global perspective, we identify the factors that adversely affect the body’s ability to heal and / or increase sensitivity of the nervous system. For example, lack of sleep and physical and emotional stress increase inflammation, which adversely affects tissue health, contributing to pain sensations. We have identified multiple factors in our patients that contribute to back pain with upright activities and standing. The key is to identify your specific issues and to address them effectively. The following guidelines will help:

1. Critically evaluate and improve your standing alignment/posture: Think of your body segments like blocks. The head, rib cage, pelvis, and feet should be aligned vertically as if stacked directly on top of each other. See pictures for ideal and dysfunctional postures. An easy way we have found to accomplish this is to first center your weight over your feet and then make sure your sternum pubic bone are aligned vertically (hand placed on the upper chest should be aligned with hand placed just below the belt line when viewed from above while looking down or from the side when looking in the mirror). Please note if you lack hip flexor or thoracic mobility achieving an upright vertical alignment is more difficult.  Here is a link https://www.youtube.com/watch?v=yVrJfzcSrT4 regarding correction of standing alignment. 
2. Ensure that you have sufficiently hip flexor mobility: if you lack hip flexor mobility, which is common in the modern population as a result of how often we sit, then maintaining a well aligned upright vertical posture is more difficult. One way to determine if your hip flexors are tight is to lie on your back, bring one knee to your chest firmly, and then let the opposite leg relax towards the floor. If your thigh has difficulty resting on the floor this can indicate the need for increased hip flexor mobility. Here is a link to one of our favorite methods of addressing this deficit. Supine Hip Flexor Stretch..
3. Ensure that you have sufficient thoracic mobility/alignment: if you lack thoracic mobility and have an increased thoracic curve then the lumbar spine will typically make up for this deficit by extending excessively in standing (particularly if there is insufficient core/abdominal control to prevent this compensation). See picture. To ascertain this look at yourself in the mirror do you have an increased forward curve in your thoracic spine or excessive curve in your lumbar spine? If this is the case thoracic mobility may be a contributing factor. A simple way to correct this is to lie on your back with your knees bent, head supported on a small pillow, and your palms facing up as if lying in sand. Relax and breathe for five minutes while imagining yourself sinking further into the sand. This exercise relaxes muscles tension and helps increase thoracic mobility with breathing. 
4. Ensure that you have sufficient core/trunk stability – control: this is a bit more difficult to determine without professional advice as there are many factors that will contribute to core function as well as how to train it effectively. At Thrive we have methods of determining an individual’s needs however, a simple push-up can be of assistance. Assume a prone face down position on the floor, place your hands just outside the shoulder with at the level of your collarbones with your lumbar spine reasonably flat with your chin down facing the floor (make sure neck is not extended and noses faces the floor). Then, while maintaining proper body alignment perform a push-up without bracing or thought of how to stabilize your trunk. If your core stability is reasonably efficient, you should be able to maintain a straight body without sagging from the pelvis/lumbar spine (without having to brace your abdominals actively). If you’re able to do this easily then your core is likely reflexically stable and responsive. If you sag or have to perform a large abdominal brace to accomplish the preceding movement then this is an area that could likely use additional work.  If upper body strength is a limiting factor then it is permissible to perform the preceding with the knees on the ground.  Here is a link to a beginning level trunk stabilization exercise that can be helpful in improving core function  Beginning Level Quadruped Stabilization..
5. Ensure that you have good hip and glute strength: the hips are essentially the motor that you should be using to walk with in addition to your core/trunk musculature (we actually generate our walk from the trunk but that is a topic for another blog). The core and hips work together functionally, and are mutually dependent on each other. If you have a weak core, you will likely have weak/suboptimal hips and vice versa. With weak hips (and core) a common substitution pattern we see in our patients, is to use excessive lumbar back muscle activity in standing and ambulation, which can contribute to back pain. A good test for this is sit to stand or standing squat as seen in the links below.  To perform this test, sit at the edge of the chair, cross your arms across your chest, hinge from the hips placing your nose over the toes and practice standing up and sitting down by pushing down through your heels. Essentially you are performing standing squat with the use of your hips. If you are able to accomplish this 30 times with good technique, while feeling the effort in your rear end (not your quads) and good balance, then your hip stability is at least somewhat functional. Here is a link to a sit to stand maneuver as well as a bridge both of which are good ways to evaluate and train for hip strength. Sit to stand. Functional Squat., Supine Bridge
6. Ensure that you have good single leg balance: in order to stand and walk without pain one must have the preceding variables but also balance, which is a good measure of how efficiently the body is working. Here is a way to evaluate it. With your weight centered over your feet attempt to stand on one foot and remain still without shifting of your body or hip. You should be able to accomplish this for at least 15 seconds without extraneous body movements, dropping/rotation of the pelvis. If this is difficult work to retrain it and improve by practicing standing on one leg while maintaining vertical body alignment and a stable pelvis.

If you are experiencing pain, injury, or weakness why suffer any longer? Take action to address it now!  Give us a call at 804 320-2220 and sign up for our complementary consultation while they are still available!  Or check out our blob or attend our monthly Thrive Movement Lab (call to RSVP second Tuesday of each month) to find out more helpful information to get you back to thriving!

By C. Clarke Tanner and your Team at Thrive Physical Therapy Inc.