Suzie Says...Look After Your Back!
So, I think most people have had some kind of back ache at some point or another? If not, you're doing well, especially if you're riding a bike for hours on end, whether it's off-road or on-road. Even if you do not suffer from back pain, it's still a good idea to do some gentle back exercises to maintain a healthy back. Back pain may affect anywhere between 60-85% of people at some point in their lives and 50% of the population over 65 experience some sort of back pain. Saying that, our back is a strong and quite resilient structure and can put up with quite a lot but it's still very worthwhile looking after it. There's a lot of fear-mongering about the back, and this can cause people to avoid lots of movements and become fearful of movement, which can actually make matters worse.
So what is the back? It could be considered as the whole spine i.e. from the base of your skull (Atlas and Axis) to the tip of your tailbone (Coccyx), which consists of 33 vertebral bones. Here I will focus primarily on lower back pain, i.e. the 'lumbar' spine, although some of the information will be applicable to the whole back.
The lumbar spine is made up of five interestingly shaped bones called vertebrae. The lumbar vertebrae are more hefty than the others as they bare a much bigger load than say the bones at the top of your spine in the neck (cervical vertebrae). I won't go into detail of the anatomy here, but if you want a good, easy lesson, why not visit the Get Body Smart website. In between all of these vertebrae are discs. These are your spine's shock absorbers, they help hold the vertebrae together (as well as keep them apart) and help allow your spine to move. The discs have a squishy inner part (nucleus pulposus) and a strong outer wall (annulus fibrosus). For discs to stay healty they need adequate hydration and nutrition, which is aided through movement.
Needless to say, 'back pain' is a HUGE topic with many factors and I could go on for hours about different aspects of the anatomy, physiology and different issues, but this is not what this blog is about...thank f**k for that I hear you say! I am unable to diagnose people without a hands-on assessment, however I will give a brief overview of some of the common conditions you may have heard of below. The main aim of this blog is to provide some advice and straightforward exercises you can do anywhere to help prevent back pain, keep your back healthy, or to use to help you if you have general back pain (only if they DO NOT make symptoms worse).
Some common issues with the back are:
Stenosis (often in older adults)
Bulging or Herniated Disc
Non-specific lower back pain
A very brief overview of these conditions:
Muscle strain - can be caused by a sudden activity and overload of the muscles e.g. lifting a heavy load, or by a build up of repetitive activity over time. Back muscle strains are often postural, fatigue-related muscle strains from sustained postures, especially if posture is bad. When soft tissues in the lower back are over-stretched or torn, the surrounding area will often become inflamed. Pain is most intense for the initial few hours/days. People often experience increased pain with certain movements or positions, like bending forward, backward, or standing upright. Ongoing moderate pain and stiffness is usually felt for 1 to 2 weeks while muscles heal. Pain when holding certain movements, anything that jars the spine, or sustained positions such as standing for long periods, stiffness, and local tenderness are quite often reported. Fortunately, this type of injury will normally settle within 6 weeks if not continually exacerbated.
Stenosis - This is often caused by degenerative changes and the most common symptom is 'neurogenic claudication' causing impingement or inflammation of the nerves from the spinal cord. Stenosis means narrowing, so the area which the nerves travel through is narrowed and many things can cause this to happen. People often suffer from lower back pain and leg symptoms, particularly made worse by walking / standing and eased by bending forwards or sitting. Ideally this needs proper assessment and also to rule out vascular issues e.g. vascular claudication, which can be mistaken for neurogenic claudication.
Bulging or Herniated disc - This is where the disc bulges or if weakened, the middle bit can protrude through the outer wall and it is therefore 'herniated'. It can be caused by accumulated microtrauma, a sudden unexpected load and also genetic factors. Poor posture in any daily activities stresses your spine. If you keep slouching or sitting/standing in a forward bending posture it can lead to overstretching and weakness of the rear side of the outer layer (or annulus) of the discs. Over time, this leads to poor disc integrity and the fluid in the middle bit of the disc is shifted back. This can place your spinal joints and nerves under pain-causing pressure. It can also cause issues like sciatica (see below). Fortunately in many cases the body is quite good at healing itself so most people recover well with symptoms reducing by about six weeks.
Sciatica - This is where your sciatic nerve (the longest nerve in the body) gets irritated or pinched and can cause pain from your back, all the way down the back of your thigh, leg to your foot. It can be caused for a load of reasons, but common causes are a bulging disc in your lower back, spine degeneration and spine joint (facet joint) injuries. Common symptoms include: Pain in the rear or leg that is worse when sitting, burning or tingling down the leg, weakness, numbness or difficulty moving the leg or foot, a constant pain on one side of the rear calf and a shooting pain that makes it difficult to stand up. Only 1 in 50 will have pain due to a hernaited disc and 80-90% of people with sciatica will recover, however if symptoms are ongoing, especially more than 6 weeks, get a proper assessment.
Non-specific lower back pain - This accounts for 85-90% of back pain. It is low back pain that can't be put down to a recognizable, known specifc pathology (e.g. infection, tumour, osteoporosis, lumbar spine fracture, structural deformity, inflammatory disorder, radicular syndrome, or cauda equina syndrome). Any structure in the spine that has a nerve supply (i.e. that has the potential to cause pain) can cause symptoms of low back and referred pain. This long list of potential structures includes the muscles, ligaments, dura mater and nerve roots, zygapophyseal joints, annulus fibrosis, thoracolumbar fascia, and vertebrae, so there's a lot going on as you can see!
Just to bring it back to biking, as motorbike riders we can have 'trauma' if we fall off hard, we can over-exert by lifting heavy bags onto our bikes, or by trying to lift bikes up, pulling them out of mud etc, but we're also susceptible to all of the injuries from bad or sustained posture. This is especially true when you spend a long time on the bike, especially on long tarmac roads or if you have a lot of vibration through the bike, don't stop very often and then, when you do stop you sit again, work on a computer etc., etc. Sadly, this is not just postural 'rubbish' and bollocks about not moving around enough; there's a tonne of evidence to show it all has a huge impact on our backs as well as the rest of the body, even if it's not noticable in the short-term.
There is a also a shit load of evidence to show that core stability exercises and general back mobility exercises can help with lower back pain. Like anything it's not the answer to everything, but it can really help. For those of you that like them, exercise programmes such as Tai Chi, Yoga, and Pilates, are all based on core stability exercise principles, so may help. There is little evidence for lots of the fancy stuff, and if you see a physiotherapist, some manual (hands-on) therapy can help but only alongside a tailored exercise programme as written in the current NICE guidelines.
Myth 1 - Moving will make my back pain worse. Myth 2 - I should avoid exercise, especially weight training. Myth 3 - A scan will show me exactly what is wrong. Myth 4 - Pain equals damage.
Below I have written down ten general exercises that are easy to do, don't require any specialist equipment and can be done almost anywhere (ish). They include both stretching and core engagement / strengthening exercises. I have taken some photos of my partner Kelvin doing the exercises to help; if he can do them, anyone can! Just remember, they will only really help if you do them regularly, not just once a week or once a month!
1. Knee Hugs (with or without adduction).
Lie on your back somewhere comfortable (ideally not a squishy bed). There are a couple of options for this exercises and you can either choose the most comfortable, the one you get the best stretch from or a combination of them.
Option 1. Pull one knee into your chest. Hold for 20-30 seconds. Release and then do the same with the opposite leg. Repeat both sides 3-4 times each.
Option 2. Pull both knees to your chest and hold for 20-30 seconds. Release. Repeat 3-4 times.
Option 3. Pull one knee into your chest and slightly inwards (knee pointing to opposite shoulder). Hold for 20-30 seconds. Release and then do the same with the opposite leg. Repeat both sides 3-4 times each.
2. Cat stretch.
Get onto all fours. Arch your back up and tilt your head down, hold 5 seconds, and then lower back down and arch it the opposite way and tilt your head up, hold 5 seconds. Repeat 10 times.
3. Child's pose.
Get onto all fours. Slowly sit back on your heels as far as comfortable and let your hands slide forwards as far as comfortable. Hold this position for 20-30 seconds. Return to the start. Repeat 3-4 times.
4. Back rotations.
Ok, again there are a couple of options.
Option 1. Lay on your back with your knees bent up, feet flat on the floor. Let your knees slowly roll to one side and hold 5 seconds. Then roll them to the other side and hold 5 seconds. Repeat 10 times.
Option 2. Lay on your back with your knees bent up, feet flat on the floor. Let your knees roll to one side and take your arms to the other side. Hold 5 seconds. Then roll your knees to the other side and arms to the opposite side. Hold 5 seconds. Repeat 10 times.
5. Hamstring stretch.
Option 1. Sit on the edge of a chair. Keep one leg bent at 90 degrees and have the other one out straight with the heel resting on the floor. Lean forwards from the hips using your hands on your leg to support you, until you get a stretch in the back of your thigh. Hold 20-30 seconds. Release slowly. Repeat 3-4 times.
Option 2. Lay on your back. Using your hands to help (or use a belt etc), bring one leg up and straighten it until you get a stretch in the back of your thigh/knee. Hold 20-30 seconds. Release slowly. Repeat 3-4 times.
6. Pelvic tilts.
Lay on your back with your knees bent up and feet flat on the floor. Slowly flatten your lower back down onto the floor so the bony part of your hips tilt towards your head, hold a couple of seconds and then slowly arch your back off the floor so the bony part of your hips tilt away from you. Hold a couple of seconds. Repeat the above for 10-20 repetitions. You can also do these on the bike, sitting up if you want something to do whilst on the road to keep your back moving.
7. Lumbar extensions.
Lay on your front and have your elbows bent with forearms either side of your chest, fingers pointing forwards (position 1). Push up on your forarms so that your upper body lifts off the floor a little (position 2). If comfortable, you can push up on your hands and straighten your elbows so more of your upper body is off the floor (position 3). With this exercise keep your pelvis on the floor. Hold 5 seconds. Relax back down. Repeat 10 times.
8. Deep core activation (including progressions).
Start: Lay on your back with your knees bent up and feet flat on the floor. Place your finger tips just inward of the bony parts at the front of your hips. Gently engage your deep core muscles and draw your belly button towards your spine a little. Some people find this easier by imagining they are trying to stop themselves going to the loo. If you cough you will feel these muscles tense under your fingers. You should feel them tense a little as you perform the exercise. Hold a few seconds. Release. Practice just switching them on and off and aim to hold for longer as you practice more. You can also do this when sat on the bike.
Progression 1: If you have mastered activation of the muscles, do this exercise but as you are keeping these muscles switched on, slowly slide one leg away from you as far as possible, making sure your pelvis doesn't tilt, and then return to the start. Repeat with the other leg. Repeat 10-15 times each side (or less if you feel you are not able to keep your pelvis stable).
Progression 2: If the last exercise is getting easy try this. After you engage your core, keeping one leg bent, slowly lift it off the floor a little. You can lift it all the way up to 90 degrees (between thigh and trunk) if you can. Hold a few seconds. Slowly lower. Repeat with the other leg. Repeat 10-15 times each side (or less if you feel you are not able to keep your pelvis stable).
Progression 3: Again, if the progression 2 is getting easy try this. Start in the same way by lifting one leg to 90 degrees slowly. This time, as you lower the leg start lifting the other one ( abit like a bicycle), making sure you keep your pelvis stable. Repeat 10-15 times each side (or less if you feel you are not able to keep your pelvis stable).
Get on all fours. Engage your core.
Option 1: Lift one arm out in front of you making sure you do not twist your body, hold a few seconds. Lower. Repeat on the other side. Repeat 10-15 times each side.
Option 2: Take one leg out behind you and lift it so it is in line with your trunk if possible. Hold a few seconds. Lower. Repeat with the other leg. Repeat 10-15 times each side.
Option 3: Lift one arm out straight in front of you and lift the oppposite leg out straight behind you at the same time in a smooth motion. Hold a few seconds and slowly lower. Repeat with the opposite arme and leg. Repeat 10-15 times each side.
Lay on your back with knees bent up and feet flat on the floor. Gently engage your core. Slowly lift your bottom off the floor and your back, vertebrae by vertebrae, until your body is in a straight line from your knees to your shoulders. Hold 5 seconds. Slowly reverse and lower. Repeat 8-10 times.
To make this harder, once you are in the bridge position, straighten one leg out without letting your hips dip, hold a couple of seconds and returen to start. Repeat 8-10 times each side.
If you are new to these exercises, start slowly and don't try to do everything all at once. If you already have severe back pain, I would recommend getting a professional assessment before starting any exercise programme so you don't do anything to make matters worse.
Other things you can do to help:
Make sure you lift correctly. If you have to lift anything particularly awkward or heavy, get help. Bend your knees, not your back, keep the object you are lifting as close to your body as possible and if you have to turn, pivot on your feet and try to avoid twisting your body.
If you are overweight, seriously consider losing some weight (for more than 5 minutes!). The strain the excess weight can put on your back will exacerbate back pain. Not only is losing weight good for your back, it's good for the rest of your body to.
Get moving. Try and do some regular exercise, even if it's just going for a short walk for 30 minutes each day. Back's like movement!
Make sure your handlebars are set up right for you so that you do not have to over stretch and so that you are not constantly in a forward lean posture. I remember when I toured around Europe on my CBR1000RR for several days on end...my back killed! All that leaning forwards, the extra strain on my back, plus being bad a stopping regularly really didn't help. Now I ride a DR650, the position is much better plus it's set up for me meaning daily back pain is a thing of the past. Obviously stopping regularly is still a must, but it's just another excuse to drink coffee, have a bite to eat and take some photos. Bike set up is so important. Also, if you ride off-road the handlebars need to be at a good height when stood so that you're not having to really bend to hold them...lowering footpegs can sometimes help here as well.
Right, so most back pain will resolve...fact! 30-40% of people will have their back pain come back within a year and if you stop moving it will get worse, not better. Keeping this in mind, there is that very, very small percentage of people who's back pain is a sign of something worse and it's important to know the signs. As a physio, I know these things as 'Red Flags'.
A few Red Flags (not an extensive list):
Changes in bladder or bowel, in particular being incontinent, unable to sense when you need the toilet, urinary retention.
Numbness in the genital or anal area.
Sudden unexplained weight loss, not associated with a change in diet, increased exercise etc.
Constant, unremitting pain, especially at night/at rest, and especially if it's gradually worsening over time.
Ongoing fever or 'general malaise' - a general feeling of being unwell.
Progressively worsening neurology i.e. major loss of power or muscles or major loss of sensation, difficulty walking.
History of cancer, long-term steroid use or IV drug use.
Recent trauma like falling from a height or being thrown off your bike in an accident, or even mild trauma if you have osteoporosis.
Drug abuse, human immunodeficiency virus (HIV), systemically unwell.
The video at the bottom of the page talks a little more about red flags, so it may be worth a watch if you are concerned.
PLEASE REMEMBER, just because you have a 'Red Flag' does not mean you definitely have a serious pathology, but if you do (especially a combination of red flags) you should seek urgent medical attention i.e. same day not an appointment in 2 weeks time. Normally, red flags are taken into account along side a detailed history by a qualified health professional (e.g. GP/Doctor, physiotherapist) to determine the best course of action and if urgent onward referral is required.
Also, if you are doing exercises, looking after your back and it is not resolving after one month, PLEASE seek a professional assessment, especially if you are over 50 years old.
A video I really like on YouTube, which gives some good advice about back pain, especially when it is persistent (aka chronic) and if you are worried about your back pain is: https://www.youtube.com/watch?v=BOjTegn9RuY Obviously, the style does not suit everyone but it's got some good, evidence-based information.
NEXT UP: I will also release a blog on higher level exercises to really ' train' your muscles ready for getting out and biking...watch this space!
References (sorry it's a bit of a long list!):
Backstrom, K., Whitman, J., and Flynn, T. (2011). Lumbar Spinal Stenosis - diagnosis and management of the aging spine, Manual Therapy, 16: 308-317.
Min-Yeong, H., KYoung K., BeoM-Young, H., CHan-Woo, N. (2015). The effect of lumbar stabilization exercises and thoracic mobilization and exercises on chronic low back pain patients. Journal of Physical Therapy Science. 27(12): 3843-3846.
Cousins, G. and Breakwell, L. (2015). Assessment and Management of Patients With Degenerative Spine Disease. Surgery, 33(6): 277-280.
Lizier, D., Perez, M., Sakata, R. (2015). Effect of Orientation Through A Booklet of Stretching and Strengthening Exercise in Patients with Low Back Pain: Booklet of Exercise for Low Back Pain. International Journal of Physiotherapy, 2(6): 1055-1062.
Waongenngarm, P., Rajaratnam, B., JanWantanakul, P. (2015). Perceived body discomfort and trunk muscle activity in three prolonged sitting postures. Journal of Physical Therapy Science, 27: 2183-2187.
Verhagen, A., Downie A., Popal, N., Maher, C., Koes, B. (2016). Red ﬂags presented in current low back pain guidelines: a review. European Spine Journal, 25: 2788-2802.
NICE (National Institue of Clinical Excellence) (2017). Low Back Pain and Sciatica in over 16's. Quality Standard. [Online]. Accessed at: https://www.nice.org.uk/guidance/qs155/resources/low-back-pain-and-sciatica-in-over-16s-pdf-75545541654469
file:///D:/Physio/For%20Website/PNZBackPainEbook.pdf via Google.