• back problems are the second leading cause of all office visits to primary care physicians (after colds)?
• low back pain is the leading cause of disability in persons younger than 45?
• the highest prevalence of low back pain is in persons age 30 to 50?
• the annual cost including disability and lost productivity is approximately $50 billion?
• the direct medical cost is $25 billion?

Perhaps even more importantly, are you aware that the majority of low back problems are preventable? Some back pain, of course, is caused by factors such as traumatic accidents, infection, malignancy (tumors) and congenital defects. This type of pain is generally not preventable (and is beyond our scope of practice). Most low back pain, however, is avoidable? if only people had the appropriate knowledge and skills. That?s where you, the fitness professional, come in. You can play an important role in reducing America?s health care costs through back pain prevention while enhancing the well-being of your students and/or clients.

BODY MECHANICS

A major factor in preventable low back pain is poor body mechanics?how an individual sits, stands, walks, sleeps, lifts and exercises as well as how he or she performs daily living activities. It is difficult to have proper body mechanics if important major muscles are weak and/or tight. Other risk factors for low back pain are loss of flexibility and muscle endurance, loss of torso stabilization, poor posture, excessive forward flexion and poor cardiovascular fitness. Loosely linked to the development of low back pain are high mental stress or inadequate coping mechanisms, obesity and smoking.

NEUTRAL SPINE

A key component necessary for understanding proper body mechanics is the concept of the neutral spine, or the spine that is in ideal alignment. Generally speaking, a neutral spine should be maintained throughout all daily activities, no matter what a person is doing. Is your spine neutral right now, at this moment, as you are reading this article? For ideal back care, we maintain a neutral spine as much as possible when standing, driving, sitting, sleeping, lifting, raking leaves, shoveling snow and, of course, when exercising! The obvious exception to this statement is that when performing specific torso exercises (such as for the rectus abdominis, obliques and erector spinae muscles), the spine will be flexed, extended or rotated and flexed, and, therefore, will no longer be in neutral. However, the spine remains neutral when performing almost all other muscle conditioning and flexibility exercises. For example, the hips and knees flex and extend in a squat, but the spine itself remains in ideal alignment (unchanged from the ideal alignment in the standing position) throughout. When performing a bent-over row for the latissimus dorsi, first place the spine in neutral and then begin to move the shoulder and elbow joints, maintaining a stable, ideally aligned spine throughout the set.

WHAT IS NEUTRAL ALIGNMENT?
 

When the spine is in neutral alignment, it should have four curves: a lordotic (inward) curve in the cervical region, a kyphotic (outward) curve in the thoracic region, a lordotic curve in the lumbar spine and a kyphotic curve in the sacral spine. None of the curves are excessive; they are in a harmonious, balanced relationship to each other. (See Fig. 1.) When teaching prevention, work with your clients not only on proper standing alignment, but on correct seated posture as well. After all, most Americans are sedentary, spending hour after hour, week after week, month after month, and year after year sitting with their backs rounded and hunched over. The majority of their upper body weight is directed into the sacroiliac area. (See Fig. 2). Is it any wonder that the incidence of low back pain is so high? When seated in correct alignment, the upper body weight is directed onto the sitting bones, or ischial tuberosities of the pelvis, while the spine remains in neutral with its four natural curves intact and in proper relation to each other. Most people have difficulty sitting in correct alignment, partly because they are unaware of what constitutes good alignment, but also because their hamstrings are too tight and their torso muscles fatigue easily. All of these factors are correctable conditions. Additionally, many chairs are poorly designed, almost forcing us into bad posture. Using a small lumbar roll, or pillow, is very helpful in maintaining the proper lumbar lordosis, or inward lower back curve, when seated. When the lower back is properly supported, it is easier for the upper back curves to be in proper alignment, and it?s more likely that upper body weight will be shifted onto the sitting bones, where it belongs. (See Fig. 3). To practice low back pain prevention, teach your clients to modify their car seats, airplane seats, office chairs, easy chairs at home or any other place where they spend a lot of time sitting.

LIFTING

Another critical area for student/client education is in proper lifting. Ideally, whenever we bend over to lift an object, we keep our spines in neutral. However, as we will see, that is extremely difficult for most people. Since it is unrealistic to expect everyone to maintain a neutral spine every time they lift something, I recommend teaching your students/clients to use a one-handed lift whenever possible. A one-handed lift can be used for picking up all objects except the heaviest or most unwieldy items. The key point about a one-handed lift is that the hand that is not lifting is free to provide support. It can be placed on the thigh or on a nearby object such as a chair, table or desk. Once the spine is supported, it is not as essential to keep it in neutral, nor is it as important to keep the abdominals contracted. In other words, a one-handed lift is ideal whenever your students/clients quickly and mindlessly pick up the dozens of everyday objects that seem to relocate themselves to the floor. For example, a parent with small children is constantly bending over to pick up Legos, Tinker Toys, bits of paper, etc. Try counting how many times per day you pick things up from the floor! Do you always have your spine in perfect alignment and your abdominals contracted? Train your clients to face the object with feet at least shoulder width apart and place one hand on a thigh, using the other to pick up (and put down) objects. (See Fig. 4). This can be accomplished in class or during a training session by having students/clients practice picking up their dumbbells. (The first dumbbell is placed into the support hand on the thigh while the second dumbbell is picked up). In fact, the one-handed concept applies to practically any time a person bends over. When brushing your teeth or getting a drink of water from a drinking fountain, for instance, one hand should be placed upon the sink or upon the water fountain for support while the other hand is working. This is how back pain prevention is practiced!

However, what if the object to be lifted is heavy, bulky or wiggly (as in the case of picking up a child)? In such a situation, a one-handed lift obviously won?t work. A two-handed lift is necessary, but two-handed lifts are much more difficult for most people to perform correctly. The proper method, with the least amount of stress to the back and knee joints, is to use a weight room-style squat. Is a proper squat easy to do? Have you found it difficult initially to get your students/clients to perform a squat with proper alignment? Most individuals have problems executing this exercise, at least at first, with a minimum of stress to the back and knees. Why? To perform a squat with ideal alignment, one needs to have flexible hamstrings, gluteals and calf muscles, strong quadriceps, hamstrings and gluteals, as well as strong, stable abdominals and erector spinae muscles. Coordination, balance and body awareness also help. No wonder so many people lift incorrectly! The good news, however, is that almost everyone can acquire the appropriate flexibility, strength, stability and body awareness to perform a proper two-handed lift. You can teach them! Here?s how (See Fig. 5):

• Feet are shoulder width apart or possibly wider. A wide stance is particularly important if the object to be lifted is very large, bulky or heavy.
• Face the object squarely and get as close to it as possible.
• When lowering the body, hips and knees will flex. The middle third of the body will move posteriorly, or backwards, with the tailbone pointing back.
• This posterior displacement allows the knees to remain over the midfoot, behind the toes. If the knees ?overshoot? the toes, a considerable amount of inappropriate joint stress is applied to the knees, increasing the chance of knee injury. Heels remain on the floor (this takes flexibility).
• During hip flexion (while lowering) and the subsequent hip extension (while lifting), a ?hip hinge? is performed, meaning that the neutral alignment of the spine (and its four natural curves) is unchanged. The spine is essentially one long, stable, neutral lever that goes along for the ride, but has no independent movement of its own.
• The head and neck simply continue the line of the spine, remaining in neutral alignment.
• The lift is actually performed by the leg muscles (quadriceps, hamstrings, and gluteus maximus) on the way up. The spine is stable and still, with the rectus abdominis, obliques and erector spinae muscle isometrically contracting.
• If the object is particularly heavy or large, it?s often helpful to actually brace the elbows against the inner thighs while adjusting the grip and initiating the lift. Widening the feet and practically straddling the object while bracing the elbows works well (especially if adequate hip adductor flexibility exists).
• Always remind yourself and your students/clients to ?set? the abdominals prior to actually initiating the lift. Never lift a heavy object with the abdominals loose or ?hanging out.?
• Reverse this procedure when setting the heavy or large object down.

SLEEP

Since approximately one-third of human life is spent in sleep, it makes sense to have the most appropriate spinal alignment possible while sleeping. What would be the best way to keep your spine in neutral alignment throughout the night? Many physicians and physical therapists agree that the most optimal position is on the side. In order to keep the hips stacked and the spine in neutral, it is helpful to place a pillow between the knees. Alternatively, lying supine may be appropriate if a pillow is placed under the knees.

ALIGNMENT MAINTENANCE

Evaluate your students/clients during exercise to be sure that they are maintaining a neutral, stable torso at all times (except during specific torso exercises). Clients often ?destabilize? their spines during the following common exercises: push-ups, lat pull-downs, seated rows, bent-over rows, overhead presses, standing hip extension and abduction, squats, lunges, all fours hip extension, seated and standing hamstring stretches, seated straddle stretch, and standing quadriceps stretch. In all these exercises, extremities are moving, but the spine is held still and in neutral.

Unsupported spinal flexion where the spine is rounded or curved and not in neutral is also considered problematic. Remember that the anterior and posterior longitudinal ligaments?the longest ligaments in the body?connect all the vertebrae together front and back. Ligaments, you recall, can stretch but cannot ?stretch back.? Once a ligament is overstretched, it remains overstretched permanently. Standing bent over with the spine flexed, rounded and hanging in space (unsupported) will gradually overstretch the posterior longitudinal ligament as it is pulled and lengthened by the upper body weight hanging on it. Overstretched ligaments lead to the very thing that we have been trying to avoid: instability of the affected joints. In this case, the ?joints? between each vertebra become more mobile, less stable and more prone to injury. The longitudinal ligaments also hold the discs in place, front and back. As the ligaments become more overstretched, the discs may also begin to bulge and move out into unintended places. As you can see, habitually placing the spine in unsupported forward flexion can increase your risk for back injury and pain. This is true in sitting as well as standing, although in the standing position there is more resistance tugging at the posterior ligament, and so the risk of overstretching is greater. There are two options for prevention (both were discussed earlier). One, if the spine must be flexed (as when brushing teeth), place a hand on something for support. Two, if the spine must be unsupported (as when lifting a heavy object), keep the spine in neutral. The concept of the hip hinge has become popular in recent years. A hip hinge is simply pure hip flexion with the spine in complete neutral, as in a ballet port de bras. If a true hip hinge can be performed, the spine is actually in a much safer position from the standpoint of ligament and disc stress than when hanging forward flexed. Practically speaking, you need to teach your students and clients the concept of the hip hinge. However, if they are unable to perform it correctly due to tight hamstring muscles (in this case, the spine will not stay neutral), a modification with one or both hands on the thigh should be given.

In addition, unsupported spinal flexion (where spine is not in neutral) combined with rotation, such as in a windmill or golf swing, is another primary mechanism of ligament overstretch and disc injury. To practice back pain prevention, avoid exercises such as windmills, which specifically place the spine in a risky position where injury is more likely. Other examples include: the full Cobra, good mornings, dead lifts, full sit-ups, V sits and double leg raises. Many so-called ?abdominal? exercises actually use the hip flexor muscles as prime movers, while the rectus abdominis and/or obliques function as stabilizers, contracting isometrically. The benefit versus the risk of these exercises must be evaluated on a case-by-case basis (generally they are inappropriate for the group exercise setting). Although there is a benefit to training the abdominals isometrically (the abdominals? role as a stabilizer is enhanced), doing so while the low back is placed in a risky position is questionable. Because the hip flexors (iliopsoas) attach to the lumbar spine, exercises which utilize the hip flexors as prime movers (such as a double leg lift) can result in large shearing forces on the lumbar spine, literally pulling the lumbar vertebrae and discs out of alignment. A client must already have an extremely strong rectus abdominis in order to stabilize the spine and prevent the risk of injury. Therefore, this exercise is appropriate only for the elite exerciser, if at all. When confronted with a popular but high-risk exercise, ask whether there isn?t a more suitable alternative?something equally effective, but with a lower risk factor. We want to help our students/clients practice prevention, not further increase their risk of injury!

IMBALANCE CORRECTIONS

Another strategy for back pain prevention involves correcting common muscle imbalances that impact the spine. These include:

• weak, loose rectus abdominis, obliques and transverse abdominis that need to be strengthened.
• tight (and possibly weak) erector spinae that need to be stretched.
• tight iliopsoas (hip flexors) that need to be stretched.
• tight hamstrings that need to be stretched.

Teach your students safe, effective and appropriate exercises that counteract these common imbalances.

PAIN MANAGEMENT

What can you tell a student or client who already has symptoms of low back pain? First, encourage them to see their physician for a diagnosis and treatment plan. Work with the physician and follow any exercise and pain management recommendations. Pain can be managed by:

• providing appropriate strengthening exercises.
• providing appropriate flexibility exercises.
• teaching relaxation techniques.
• nonprescription analgesics (check with the physician).
• practicing proper body mechanics (as described in this article).
• relaxing tight muscles with massage and/or whirlpool bath.
• providing comfort with heat and/or cold.

COLD APPLICATION

In general, cold (ice) is usually used during the first 24 to 48 hours of pain onset to reduce active inflammation and pain. Inflammation includes edema (swelling), hemorrhage (bleeding), muscle spasm and pain. Cold helps reduce edema by causing vasoconstriction of the superficial blood vessels. This, in turn, reduces arterial and soft tissue blood flow, helping to minimize hemorrhage. Cold also helps to manage pain by reducing muscle spasm and by blocking sensory nerve impulses that carry pain messages to the central nervous system.

Guidelines for applying ice include: wrapping a bag of frozen vegetables or crushed ice in a washcloth or plastic bag and apply it to the injured area; place a thin towel between the ice and the skin to help minimize the risk of frostbite injury; apply for no longer than 20 minutes at a time, three to four times throughout the day, but not more often than every two hours.

HEAT APPLICATION

Heat is often used after the first 24 to 48 hours to reduce pain, relieve muscle spasm, and improve local blood flow. Superficial heat acts as an analgesic (pain moderator) by causing vasodilation. This increased blood flow helps remove metabolic by-products that can stimulate pain receptors, as well as encourage the influx of nutrients leading to tissue repair. Heat decreases muscle spasm or tension, which is a major factor in the perception of pain. In addition, heat increases the elasticity of tissues, leading to increased range of motion and greater comfort during daily activities. An increase in elasticity can help exercisers ?loosen up? and enhance athletic performance. Heat seems to be ideal for muscular strain type injuries of the neck and low back, areas that tend to be prone to muscle spasm after injury. If no acute injury has occurred, use cold or heat, whichever feels better to the student or client.

Guidelines for applying heat include: apply moist heat for approximately 30 minutes, no more frequently than every two hours; keep heat source temperature below 110?F; avoid lying directly on a heating pad because it may lead to a burn injury. If possible, maintain activity, especially range-of-motion and stretching exercises, while applying heat. A heat wrap, such as Procter & Gamble?s ThermaCare??, provides long duration (approximately eight hours), low-level, conductive heating at a constant temperature and is safe and easy to use. Some practitioners advocate applying heat before exercise to increase elasticity and enhance range of motion, and icing the injured area after exercise to reduce any resultant inflammation.

CONCLUSION

In summary, you, as a fitness professional, can be proactive about low back pain prevention by:

• teaching your students and clients about the importance of maintaining a neutral spine.
• encouraging proper standing posture.
• teaching correct seated alignment, including how and when to use a lumbar pillow.
• teaching the ?one-handed lift.?
• teaching students and clients how to squat correctly and having them practice lifting heavy or large objects from the floor with proper alignment.
• discussing ideal alignment when sleeping.
• making sure that students and clients maintain a neutral spine during all exercises except those specifically for the torso.
• avoiding as many high risk exercises as possible. Always choose the safer option unless the client has a particular sport-specific reason for needing to perform the risky exercise.
• correcting common muscle imbalances: strengthen the abdominals, stretch (and eventually strengthen) the erector spinae, stretch the hip flexors and hamstrings.
• teaching relaxation and pain management techniques.

As fitness professionals, we have the opportunity to make a difference in America?s soaring health care costs and, on a more interpersonal level, to reduce pain and suffering in ourselves and our students, clients, friends and families. People need skills and education and we are in a prime position to deliver just that! Just as most of us try to eat right, exercise, maintain a proper weight and avoid smoking in order to keep our risk of heart disease, high blood pressure, high cholesterol and diabetes down, we can follow the 10 strategies listed above to minimize our risk of back pain.

Mary Yoke, M.A. is an adjunct professor at Adelphi University in New York and trains fitness instructors and personal trainers throughout the world. She also presents wellness seminars to the general public, and review.