Back RX: A 15-Minute-a-Day Yoga- and Pilates-Based Program to End Low Back Pain

Introduction:
The Back Rx Way to a Healthy, Pain-Free Back

If you're reading this book, you're probably all too familiar with the pain of a low back injury. A strained muscle in the low back can make you gasp with pain at the slightest movement. The herniation of a spinal disk, the most troublesome cause of severe low back pain, can virtually cripple you. Worst of all, in the aftermath of a low back injury, pain may take up permanent residence almost anywhere in the back or legs, including sites far removed from the point of injury.
If you're hurting now, skip ahead to page xvii for some simple ways to ease the pain. Come back to read these pages when you're feeling better. In order to make a full and lasting recovery from low back pain, you must first understand what causes it.

In North America, four out of five people will suffer a serious episode of low back pain at some point in their lives. Only the common cold causes more lost work days than low back pain for adults under forty-five years of age.
Low back injuries usually heal within weeks, a testament to the back's inherent strength and resilience. But long-term healing is notoriously difficult to achieve. One episode of low back pain generally leads to another. Four out of five people will suffer a recurrence within one year, and then face a 70-80% risk of further recurrences. The right treatment can make all the difference between healing completely, building a more injury-resistant and resilient back in the process, and falling into a downward spiral of recurrent injury that defeats every measure of conventional and alternative care and leads to failed back syndrome, long-term dependency on pain medication, and even surgery. That downward spiral traps far too many low back pain sufferers.
I've had to heal my own low back pain. So I write this book both as a physician and as a fellow sufferer. The Back Rx program enabled me to beat my low back pain for good. And it has helped thousands of patients I see in my sports medicine practice and research at the Hospital for Special Surgery, an affiliate of Cornell University Medical Center in New York, where I also serve on the faculty as a professor. Back Rx achieves these results by blending carefully selected elements of rehabilitation, yoga, and Pilates with a central focus on breath control. It is one of the few exercise programs for the low back to be shown effective in controlled clinical trials.
In an ongoing study, my research colleagues and I are monitoring the progress of two groups of low back patients who receive the same medical care and take the same pain medication, except that one group does the Back Rx program for fifteen minutes three times a week. At the end of the first year, the group doing Back Rx had a 70% success/cure rate (as measured by a more than 50% reduction in low back pain), whereas the other group had only a 33% success/cure rate. The group doing Back Rx also needed much less pain medication and had significantly less recurrence of back pain than the other group.
Building on the work of many other low back pain researchers and clinicians at the Hospital for Special Surgery and elsewhere, my research and clinical practice have demonstrated that an exercise program like Back Rx can be the key to healing low back pain without surgery or long-term dependence on medication.

My patients come from every walk of life, including professional sports, which allows me to see the full range of low back problems. Professional athletes are especially interesting patients in this regard. Understanding why even highly conditioned individuals are susceptible to low back pain provides great insight into the common denominators of this baffling medical condition and how best to address them. I see professional athletes as private patients and in my role as a consulting physician for the ATP tennis tour and the PGA golf tour. My involvement with both tours began with research studies whose results provide powerful evidence for the effectiveness of the Back Rx program. I initiated this research in 1999-2000, when I spent a year on the road with the ATP tennis tour.

During my year on tour with the ATP, I had two main jobs to do. One was to find qualified low back care physicians in the tour's many stops around the world, from Tashkent, Uzbekistan, to Moscow, Russia, to Rome, Italy, to Tokyo, Japan, to Shanghai, China. The other was to conduct a research study into why low back pain is so prevalent among professional tennis players.
The study I conducted found that the players most susceptible to low back pain had the least range of motion in the hips. In 2001 the PGA asked me to do a parallel study of professional golfers. This study produced the same results, showing a significant link between a restricted range of motion in the hips and the incidence of low back pain. This finding is important for the rest of us, whether we are fitter than average or committed couch potatoes, because of the sedentary nature of modern life and work. Sitting in chairs, which most of us do for long hours every day at work, school, and home, leads inexorably to a restricted range of motion in the hips.
The Back Rx program accordingly features exercises specifically designed to counteract this tendency and increase the range of motion in the hips.

The treatment room at a professional golf or tennis match is a microcosm of the low back pain world. On one table a top-10 player may be receiving treatment from an acupuncturist, while different competitors work with chiropractors, massage therapists, and osteopaths, as well as specialists in conventional physical therapy and rehabilitative medicine. I have observed that although no single one of these therapies works for everyone, each of them works for large numbers of people. Back Rx incorporates insights and healing knowledge from all of them, and in the course of the book I will offer guidelines for choosing which treatments are best suited to your own individual needs.

One thing that everyone who studies and treats low back pain agrees on is that it is fundamentally a mind-body problem. As we'll see in more detail in Chapter 2, emotional factors and psychological stress play a major role in the onset and persistence of low back pain.
A number of books have emphasized the mind's role in low back pain in a conceptual way, without offering reliable, concrete methods for putting the concept to practical use. The way one recent book puts it is typical: to heal low back pain, it tells readers vaguely, "learn to work with your negative feelings." Negative feelings from stressful experiences can indeed hinder full recovery and heighten recurrences. But healing low back pain begins not with psychotherapy, but with mind-body physiotherapy. You have to engage the mind at the fundamental level of body awareness, posture, and balance first. These three fundamentals form the essential foundation for healing the whole person.
Back Rx meets this challenge and teaches you how to engage the mind in healing through its focus on breath control, a key feature of both yoga and Pilates.
In my sports medicine and back care practice, my research on low back pain, and my own efforts to lead a healthy lifestyle, I've gained an increasing appreciation for the benefits of yoga and Pilates. Yoga, which I first learned to do at my grandfather's side as a young child in India, engages the entire body in healthy breathing, while freeing the mind to focus without distraction or anxiety on anything it needs to do. This age-old practice has a mind-body potential that the latest neuroscience is only beginning to understand. For its part Pilates, whose founder, Joseph Pilates, was greatly influenced by his study of yoga, is the best strengthening practice yet developed for the core body muscles--of the torso, back, abdomen, pelvis, and thighs--that are crucial to good back health.
The paradox is that although yoga and Pilates are ultimately the best possible way to maximize back health, in the short run the vigorous twists, turns, and bends of advanced yoga and Pilates can actually cause back injuries. It's quite a catch-22: the very thing that can help you the most can very easily hurt you.
Back Rx solves this problem with a carefully sequenced introduction of yoga- and Pilates-based movements and poses that will strengthen the back without traumatizing it. From the first step on, this sequence of medical yoga and medical Pilates addresses the body and mind together by showing you how to find and follow your natural breathing rhythm. The slow, sustained, deep, gentle breathing of Back Rx helps you in two ways. It automatically clears and refocuses the mind, and thus begins to melt away emotional and mental stress without any direct mental effort or concentration. And it tunes the body, so that each deepening breath progressively relaxes and conditions injured or atrophied muscles.
There are three series of Back Rx exercises to heal and strengthen your back. Each series takes fifteen minutes to complete and should be done three times a week for eight weeks on average. Series A alone will get you moving pain-free again after an acute low back injury. Many patients maintain good long-term back health by continuing to do Series A regularly, without moving on to Series B or C.
For those who want to raise their back fitness for sports and recreational enjoyment or as a stress-, injury-, and age-fighter, however, Series B offers a vigorous back toning routine and Series C provides a strenuous core body workout.

The vast majority of low back pain sufferers, more than 80%, can heal with Back Rx alone. For the small percentage who need to take other measures as well, Back Rx can be the spine that holds an effective treatment program together. There are exciting developments that can minimize the invasiveness and maximize the benefits of back treatments and surgeries. I look forward to telling you about them later in the book, including some minimally invasive, nonsurgical procedures that I have been fortunate enough to help innovate.

The Back Rx prescription offers a comprehensive mind-body solution for the mind-body problem of low back pain. Its combination of the most advanced modern medicine with the ancient wisdom of yoga and the core strengthening of Pilates will empower you to take your healing into your own hands and become your own best physician. The ancient yogists calculated that a human being takes 21,600 breaths a day, and the goal of yoga is to make every single breath a completely healthy one. If you can incorporate Back Rx into your life, you'll make a great start at reaching that goal and living pain-free.

Low Back Pain First Aid Chest
What to Do if You're in Pain Right Now

After a low back injury, follow these simple steps to ease your pain and begin your healing.
* Focus on and regulate your breathing. Proper breathing in a slow, controlled rhythm is the fastest pain reliever you can use. It shifts the mind's attention away from the pain and triggers the body's natural relaxation response. You can do this in any position, but if possible:
* Lie flat on the floor on your back with your knees up and your lower legs resting on a chair, an ottoman, or some pillows, or lie on your side in bed in a fetal position with a pillow between your knees. These positions should take the strain off your lower back, but if another position feels better, that's fine. Every injury is different. Let your body guide you into the least painful position possible.
* Slow your breathing down as much as possible. Exhale fully, then inhale deeply and hold the breath in your lungs for a count of three. Exhale fully, and continue breathing in this way for at least two to three minutes.
* Repeat this process throughout the day to calm yourself and to deliver extra oxygen to overstressed muscles and disks, allowing them to begin to relax, breathe, and take in nourishment.
* Use visual imagery to guide your breathing and enhance the relaxation response. For example, try imagining your breath as a wave of golden light flowing through your entire body. Another good technique is to picture yourself in a favorite spot, real or imagined, where you feel safe and at ease.
The more relaxed your breathing becomes, the less pain you will feel. As you become better able to focus on your breathing for a few minutes at a time, you will also prepare your mind and body to work together in the rest of your healing.
* Pain or Gain. Being overly stoic may actually slow your recovery. Take anti- inflammatory and pain-relief medication to speed healing.
* The most readily available over-the-counter pain relief medicines are aspirin, ibuprofen (Advil), and acetaminophen (Tylenol). Ibuprofen is generally the best choice for low back pain, because unlike acetaminophen, it combines pain relief and anti- inflammatory benefits.
* Liquid gel pills work best, because they are absorbed more readily in the bloodstream. As a general rule, unless a doctor prescribes otherwise, you should take two liquid gel ibuprofen two to three times a day.
* Everybody reacts to medicine slightly differently, and you may find that it helps to to combine ibuprofen with acetaminophen, taking the first for pain and inflammation and the second for additional pain relief. In any case, do not take more than eight pills a day, total, unless your doctor prescribes otherwise.
* People with diabetes should be especially careful not to take high doses of these medicines for extended periods, because of the potential for kidney damage. Anti- inflammatory medication is also contraindicated for those with a history of gastric ulcers or compromised kidney function.
* If severe pain persists after seven to ten days of taking ibuprofen and/or acetaminophen, you should consult a physician.
* If over-the-counter medicines don't lessen your pain and inflammation significantly, don't wait a whole week to go to the doctor. More powerful pain relievers, anti-inflammatories, and muscle relaxants are available by prescription, and they are safe if used as directed.
* Like over-the-counter remedies, these medicines should only be taken short term. If they have not brought you any significant lasting relief after a few days, you should re- consult your physician.
* A number of herbal and other remedies are available for treating low back pain. These include herbal medicines prescribed by practitioners of traditional Chinese medicine and packaged natural and synthetic compounds sold by health food stores. Herbal medicine has great potential health benefits. The problem with herbal remedies, however, is that their benefits and drawbacks, if any, have not yet been tested in controlled studies. Some of them contain substances that could cause serious harm. For example, many Chinese herbs contain atropine, a substance that affects heart function. Equally important, the quality of herbal remedies varies widely. You cannot always be confident that you are getting the advertised ingredients in the right form. It is far safer to stick with well-tested over-the-counter and prescription medicines.
* Take modified bed rest for two to three days. This means that you should:
* Spend most of the day resting quietly in the most comfortable position you can find. The two positions that work best for most people are on the side in a slightly fetal position with a pillow between the knees, or flat on the back with the legs raised. The second position really encourages the lower back muscles to relax because it takes all the strain of gravity off them. These are also generally the best positions for sleeping at night.
* During the day, get up every hour or couple of hours to walk around a little and arch your back backward, to prime the body for a gradual return to full activity. You can also try some light stretching, by pulling each knee up to your chest for a moment or two. Go just to the point where you feel the strain about to become intense, stop there, and take two or three slow, controlled breaths. This is also a good idea if you find you can't sleep through the whole night, which is often the case when a low back injury is fresh.
* Avoid chair-sitting.
* Avoid lifting anything heavy.
* Instead of walking and stretching in the initial recovery phase, seniors should substitute riding a stationary bicycle. Seniors may also find chair-sitting comfortable, because their low back pain usually comes from stenosis, or narrowing of the spine, rather than from a strained muscle or herniated disc. See Chapter 2 for more on these age- related differences.
* If you have access to a pool, aquatherapy can speed your recovery. Your buoyancy in the water will take all the pressure off the low back.
* In the first twenty-four to forty-eight hours after a low back injury, apply ice to tender areas two to three times a day for ten to fifteen minutes at a time, in order to lessen inflammation. Keeping the ice on for longer won't give you any added benefit; it reaches its maximum efficacy after about ten minutes.
* After twenty-four hours apply moist heat in the shower or with a heating pad for up to thirty minutes at a time as desired. Unlike cold, gentle warmth may continue to provide an increased benefit if it is applied for a longer period of time.
* After twenty-four to forty-eight hours, use heat and ice in sequence. As a general rule, apply heat in the morning and before physical therapy or other activity; apply ice after activity and in the evening at dinnertime or bedtime. But some people get more relief from heat, whereas others get more from ice, so modify the sequence to fit your own needs.
* Apply liniments and rubs like Tiger Balm, Sportscreme, and BENGAY to soothe injured areas. The "active" ingredients in such products are usually some form of rubbing alcohol, and they never penetrate below skin level. But the act of applying the rub, or having a partner or relative do so for you, can itself be calming and beneficial from an emotional and psycho-physiological point of view.
* As the pain of your injury decreases, gradually increase your activity following the guidelines in Chapter 6 and begin Back Rx Series A.

Part one

Chapter one
How Your Back Works

The Healthy Back is a Back in Balance

The human back is a marvelously evolved structure, the supportive center of every imaginable movement. We can see that in the way young children roll and tumble as they play, and in the way champion athletes and master practitioners of yoga, Pilates, tai chi, dance, and other movement disciplines have trained their bodies to perform.
The free and easy movement of childhood is everyone's birthright, but most of us have lost it by the time we are adults. That doesn't have to happen. And if we do lose the joy of movement, we can almost always regain it.
One of the most important things to know about the low back is that a high level of pain does not necessarily indicate severe damage. The pain of a low back injury can be worse than a root canal without an anesthetic, but even the most painful injuries seldom pose any serious threat to the spine or brain. The vital parts of the body are simply too well protected for that, except in the most extreme cases. So don't lose hope or fear the worst because the pain is bad. If you follow the pain-relief guidelines on pages xvii-xx and do the exercises in this book for fifteen minutes, three times a week, the odds of a full and lasting recovery are overwhelmingly in your favor.
The human back is so robust because of the way its intricately interwoven parts reinforce each other. The back's function is to support balanced movement and posture and to protect the nerve bundles within the spinal cord. These nerves, the body's information superhighway, carry electrical impulses to and from the brain, where the impulses are translated into sensations, images, emotions, and thoughts.
The back does its job with a hardy structure of bones, muscles, tendons, and ligaments. Layers of muscle--thirty-one muscles tie into the pelvis alone--wrap protectively around the spine, which makes a gentle S-curve from the neck to the tailbone, or coccyx. The spine has twenty-four vertebrae separated and cushioned by the intervertebral discs, which are shock absorbing, doughnut-shaped pads made up of a soft inner portion, the nucleus pulposus, and a hard outer portion, the annulus.
There are seven cervical, or neck, vertebrae (commonly referred to as C1-C7, counting from top to bottom); twelve thoracic, or chest vertebrae (T1-T12); and five lumbar, or lower back, vertebrae (L1-L5). If a physician or other caregiver diagnoses a low back problem located at disc levels L4-L5, for example, this means that the focal point of the injury is in the area of the fourth and fifth lumbar vertebrae and the disc sandwiched between them.
All of the vertebrae have small projections called facet joints that stabilize the spine and allow it to move in different planes.
Below the fifth lumbar vertebra is the sacrum, a triangular-shaped bone with five segments (S1-S5) that attach to the pelvis (or ilium) to form the sacroiliac joints. Together with the body's core muscles, the back's S-curve can gently dissipate the energy of harsh impacts or sudden, wrenching movements like a giant spring, and the fluid that fills the soft inner portion of the discs can absorb shocks better than any other known substance. That is, as long as we maintain them in good shape.
At birth the discs are 80% water. As we age, they gradually lose water, stiffen, and turn brittle. Nothing can entirely stop this natural aging process. But as I'll explain in Chapter 4, proper back exercises can be a great age-fighter, dramatically retarding the discs' loss of water and keeping us flexible and resilient.

To stay out of pain, the back has to stay in balance. All of its interlocking parts have to work in harmony. For example, the neuromuscular system works through paired muscles and muscle groups, like the biceps and triceps. The biceps lets you bend your arm, the triceps lets you extend it. Similarly, in the low back, the abdominals let you bend forward, whereas the paraspinal muscles let you extend straight and arch backward. If one muscle or muscle group is disproportionately stronger or weaker than its opposite number, the whole system will suffer.
As I mentioned in the introduction, one muscle imbalance that tends to be especially significant for low back pain is the poor flexion and reduced range of motion in the hips, which results from too much sitting in chairs. In Chapter 2, we'll look more closely at how chair-sitting upsets the body's natural balances and how we can restore them.

The back's need for balance includes a balance of the body and the mind. In terms of the neuromuscular system, a relaxed, balanced posture depends on a host of tiny cells, called proprioceptors, that feed data on position and movement from the muscles, tendons, joints, and inner ear to the brain. To test how proprioception works, try this experiment: Stand on one leg with your arms extended straight out to the sides at shoulder height. You'll probably notice a little wobble, but nothing you can't control. Now increase the difficulty by closing your eyes. The wobble gets worse and before long you'll have to open your eyes and put your foot down to regain your balance. Proprioception is what enables you to hold the position even briefly, and the better your proprioception the longer you'll be able to hold it.
Proprioception underlies all of our body awareness. With good proprioception, we sense intuitively when our bodies are in proper alignment and we instinctively walk and move with good posture and balance. This helps the back by enabling the discs to breathe. Like the rest of the body, the discs depend on the circulatory system to bring them essential, nourishing oxygen. Blood vessels at their periphery are the final stage of this delivery system, so far as the discs are concerned.