If the identification and resulting prevention of the incidence of low back disorders is to become a real possibility, meaningful testing of the lumbar muscles must be produced. Testing must not only include the measurement of the specific strength of these muscles but their range of motion and their “typing” with regard to muscle fiber distribution and the resulting recuperative capacity.

Very recently, an exhaustive study of low back function was conducted at The University of Gainesville, College of Medicine and College of Health and Human Performance. In this study , the development of a new testing machine which meets all of the mechanical criteria for accurate lumbar testing was described and tested. The machine eliminated pelvic involvement, stabilized the pelvis and the femurs and consistently and accurately measured the strength curve of the lumbar muscles in isolation in a range of seventy two degrees of lumbar extension.

In addition, this extensive testing project provided data which indicated that maximal power is produced in the fully flexed position and is proportionally weak in the heretofore reported extended position. The disproportionality of lumbar strength capacity as demonstrated by the test results of 25 healthy volunteer subjects reflected the poor state of condition considered normal. After a ten week strength training program conducted once per week, the subjects gained 104% at zero degrees (full extension) and gained 42% at seventy-two degrees (full flexion). This result demonstrates rather vividly the poor condition of the “normal” population’s lumbar back musculature.

Testing for Work Capacity

If the cost of caring for low back disorders is to be reduced to any substantial degree, two processes must be accomplished accurately and objectively: First, the functional capacity of the lower back muscles must be measured and secondly, occupational, recreational and social conditions must be adapted in order to reduce the possibility of superseding that functional capacity to the point of injury.

The following information has little support in the published literature. Most of this information formed the basis of a doctoral dissertation that this writer developed for a degree in exercise physiology and is the result of clinical observation and testing conducted by this writer.

If the musculature involved with lumbar support and movement are in a healthy state of condition, very little in the way of chronic or abuse injuries is likely). It would logically follow that if reliable, accurate testing of the involved muscle groups were possible and practical, work capacity could be precisely predetermined. In that area, some very simple questions must be answered with regard to the working or performance capacity of the muscles in question. First, what is the strength potential of the muscles? Second, what is the strength curve i.e. the progression and variation of available strength potential? Third, what is the fatigue and recovery effect of specific levels of exercise on the strength and strength curve?

If these three questions are pertinent and if they are accurately answered, then work hardening or preparation or prevention of low back injuries is not only possible but highly likely.

The Application of Exercise Principles for Low Back Treatment

When an individual becomes “an expert” in some particular field of endeavor, that individual, given reasonable communicative skills, should be capable of simple, understandable explanations concerning that field. It is this writer’s experience that many “experts” wear their alleged expertise like shields with which to ward off the possibility of shared understanding of their special subject as if their level of accomplishment is inversely proportional to the number of individuals who can understand their subject. Exercise is a complex and an inexact science. However, the application of exercise is almost always simple once the objective has been clearly determined.

For the purpose of identification and treatment of low back disorders, the following exercise principles must be understood and applied: Muscles produce force, nothing more and nothing less. They can maintain force for limited periods of time. The greater the force produced, the shorter the period of time that it can be sustained.

Recovery is another factor which varies on an individual basis but remains consistent for each individual once it is accurately determined. For the singular purpose of the muscular strength development, a relationship exists which is obscurely developed in the literature. This relationship is not only vital for conditioning purposes but just as important for the determination of work assignments and descriptions for those subject to increased risks of low back injury. The relationship referred to should be called the anaerobic endurance ratio but this term is not found in the literature.

Simply stated, the anaerobic endurance ratio is the relationship of the existing maximum strength level to the capacity to perform muscular work at some lower level of strength. This ratio is different for each individual but remains absolutely constant for each individual. “This relationship never changes except in the case of injury and then returns to normal when rehabilitation is complete”.

The importance of this concept is simple. Once the anaerobic endurance ratio is known in any individual case, then strength can be determined by measuring endurance and endurance determined by measuring strength. Since it has been previously determined in this presentation that it is now possible to accurately isolate and measure lumbar function, the following exercise principles can be precisely applied for the identification and treatment of low back disorders:

Measure and determine the existing strength curve and range of motion of the lumbar muscles of the back using a device which completely isolates and anchors the pelvis. Such a device exists and is currently being used in a number of clinical, university and industrial settings. This data will serve as a baseline for later comparison and analysis of treatment effect.
Compare the baseline strength curve with that of a normal range strength curve and determine if aberrations exist within the strength curve or range of motion which might predispose the individual to potential low back problems.
Prescribe a full range, balanced form of resistance training for the lumbar muscles specifically and the support and assistance muscles of the lumbar area including, the abdominal, gluteal, quadriceps and hamstring muscles.
Re-test the individual after four to six weeks and reevaluate the strength curve and recovery capacity of the individual.
As a result of step four, three courses of action may be taken:
lace the individual on a maintenance program once he has attained a normal range of lumbar function.
Continue the existing rehabilitative program if it has improved the condition.
Reevaluate the individual completely, including any medical, psychological or mechanical testing which is appropriate.

The exercise protocol must be prescribed on an individual basis but all the information upon which the prescription should be prudently developed is available when the aforementioned testing is properly performed. The determination of the strength curve, recovery capacity and anaerobic endurance ratio will establish the necessary frequency, intensity and duration of the appropriate exercise program.

Social Change

The documented cost in terms of dollars, pain and social upheaval incurred as a result of low back disorders insures that any preventive measures which can substantially reduce that cost, will necessarily enhance the quality of life within that society. Certain of the established social institutions which deal rather directly with low back treatment and payment for such treatment, including medicine, education and industry, must certainly become more responsive to the progressive approaches provided in this presentation. If, as determined by the data, low back disorders are primarily mechanical in nature, it is rather apparent that preventive measures and early detection must revolve around the accurate assessment of the mechanical i.e. musculo- skeletal capacity of the low back.

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Lumbar Function

Lumbar function has been described in the literature in hundreds of books and thousands of articles. However, until very recent developments in the fields of non-invasive imaging and biomechanics, the actual involvement of the lumbar spine with regard to its role and response to muscular stimulation, i.e. movement, has been impossible to specifically ascertain. The primary function of the lumbar region is the movement of the torso in relation to the pelvis. Although often misstated in the literature, the movement in the lumbar region is limited to extension. The normal lumbar spine cannot rotate and cannot, technically, flex. The shape and the mechanical relationship of the spinal facets from the sacrum up to and including the eleventh thoracic vertebra (T 11) prevent rotational functional on a longitudinal plane.

In published reports which indicate vertebral rotation in the lumbar area, no real immobilization of the pelvis was reported. The pelvis can rotate and cadavers can be rotated in the lumbar area but the lumbar spine of a living subject can not be significantly rotated without producing damage. The muscles, ligaments and facets of the lumbar area are designed to produce four functions:

Lumbar extension,
Prevent lumbar rotation,
Limit lumbar flexion and
Limit lateral bending.

The muscles of the buttocks and thighs can rotate the pelvis around the heads of the femur and therefore produce corresponding movement in the lumbar region. It might be interesting to note that the lumbar spine moves even in the absence of lumbar muscle contraction.

None of the aforementioned mechanical information is of any practical value unless the following two points are clearly understood:

It is widely held that extension (of the spine) produces compression forces on the lumbar discs by reducing the vertical distance between the vertebrae at the rear, thus compressing the discs and
In reality, extension actually INCREASES the disc space along the rear face of the vertebrae. Therefore, instead of increasing the forces on the discs (all other factors remaining equal), extension REDUCES the forces on the discs!

The practical significance of these two points is rather simple. Causes of low back injuries may have been historically misdiagnosed and rehabilitative protocols may, in fact, exacerbate existing c nditions.

Lumbar Function Versus Back Extension

Traditionally, lumbar function was synonymous with back extension with regard to the measurement of strength and range of motion. In most cases the isolation of the lumbar spine was neglected when testing was performed and the action of the back extension measured resulted from a significant contribution of the buttocks (gluteal group, maximus and minimus) and the thigh biceps or hamstring groups (semitendinosus, semimembranosus and biceps femoris). The aforementioned is not an exercise in irrelevant kinesiological braggadocio because while it is certainly true that lumbar function is usually involved in back extension, it is also true that back extension is primarily the result of the muscles that move the pelvis in relation to the legs (the hip extensors).

Until and unless these hip extensor muscles are removed from the equation, lumbar function cannot be accurately measured. It is normally the power of these large muscle groups which expose the lumbar area to forces which supersede the momentary potential of the lumbar muscles. The basic mechanical cause of low back injury is the “weak link” status of the lumbar muscles. If a solution to low back injuries is to be developed, practical solutions to these mechanical problems must be achieved. While many may not be interested in exactly how and why something works, or why something does not work” in this instance it is very important to understand both the solutions and the problems”.

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Hollinsworth and Watson conclude that “psychological stress from chronic low back pain is considerable and may be anticipated”. They continue that continual attention be paid to the psychological adjustment and the stress under which these individuals are placed. It is also suggested that psychological profiling be considered pertinent to the planning of management and rehabilitation of the chronic low back patient.

One more substantial study must be reported as significant with regard to the statistical implications and ramifications of low back injuries. In 1986, the Vermont Rehabilitation Engineering Center for Low Back Pain developed a computer model for the purpose of predicting the predisposition of disability as a result of low back injury. The following are some of the most significant findings of the Vermont study:

Ninety percent of individuals suffering from acute low back pain recover within three months.
The remaining ten percent of low back patients become “chronic”.
These ten percent of the population account for eighty percent of all expenditures for treatment and compensation.
Workers who are disabled for more than six months “are unlikely to ever return to work” .
Psychological factors were not correlated to prediction of disability. In fact, the conclusion stated was that psychological factors related to low back patients were consequences rather than precursors of disability.
Rather than the factor of heavy lifting as a correlate to low back injury, this study implicated poor postures and inadequate seating as significantly correlated to low back episodes.

The amplitude and frequency of vibrations encountered during driving was demonstrated to be the cause of most of the job related back episodes encountered by truck drivers and the heavy driving lay public.

The significance of the aforementioned studies propose that back disorders are predictable with regard to behavior and in some instances, psychological profiles. The use of these risk profile characteristics appears to be a prudent mechanism for the prevention of low back disorders. The next section of this article will deal with the evolutionary, developmental and mechanical implications of low back syndrome.

The Evolutionary Implications of Low Back Disorders

It would be substantially irresponsible for any researcher to consider the causes of the pervasive category of conditions indexed under low back disorders without dealing with the evolution of the human animal with specific emphasis on the spine. After all the analyses, computations and theorizations are considered, back problems are manifested as mechanical malfunctions.

The question arises as to the basis of the widespread occurrence of low back disorders in the human species. This strata of musculo-skeletal problems is manifested in all segments of the population in a generally inclusive pattern. Simply stated, the low back appears to be the Achilles Heel of the human skeletal system. Some very well founded evidence seems to support the theory that the evolution of the Homo sapien as a bipedal (erect, two legged) animal is the intrinsically causal factor in the development of low back disorders. In his influential text, The Fossil Evidence for Human Evolution: An Introduction to the Study of Paleoanthropology, Clarke (1978) observed, “The muscular anatomy of men and apes is astonishingly alike, even down to some of the smaller details of the attachments of many of the individual muscles”. However, Dr. Clarke fails to point out that apes use their arms to support their horizontal posture and propel their locomotive efforts. Apes have very few low back disorders for rather apparent mechanical reasons.

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Since the majority of low back traumas occur as a result of an acute or chronic exposition of the musculo-skeletal system to forces which supersede the momentary potential of the affected anatomical region, it makes very good sense to condition those historically vulnerable areas. The historical attempts in both Canada and the United States to pre-condition workers has been reported to be ineffective. Most of the industrially organized back training programs can be generally categorized as poor with regard to compliance and content. Either the directors of these in house programs must be more thoroughly trained and/or the curricula must be expanded both in duration and scope in order to make substantial inroads into the problem of poor physical conditioning of workers.

At this point in time, prevention training approaches consist primarily of simple lectures dealing with basic anatomy and bio-mechanics. In addition, some of the more advanced programs include obstacle courses which are designed to simulate on site working situations. If the instructor is knowledgeable, these obstacle courses can be very productive tools in exposing the worker to potentially harmful situations. Simple lifting and postural techniques may be practiced and the worker can literally train the body (specifically the low back) to prepare for the hazards of the working environment. Specific principles of exercise and conditioning for the prevention of low back problems will be dealt with in detail at a later point in this presentation.

Treatment and Rehabilitation

At the industrial level, back problems must be categorized as either chronic low back pain or an acute episode of back dysfunction. The specific etiology of most back conditions is difficult to diagnose. However, even the investigators for major insurance carriers agree that back pain is real and acute.

In prolonged cases, orthopedic and neurological examination may be employed and conservative physiotherapy prescribed. When it is determined that the patient can return to work, the aforementioned “back school” concept may be utilized in order to condition the worker for the specific functional performance required by the task of his employment. This concept has been well received in Sweden and is increasingly utilized in the United States. At this point in time, “further investment in both ergonomic and medical research is essential if the problem of low back pain in industry is to be effectively controlled”.

Who are the Most Likely Candidates for Low Back Disorders?

In order to accurately screen potential low back patients and utilize the preventive risk profile approach to identification of low back candidates, some significant data must be recognized. In another landmark study, Hollingsworth and Watson (1980) offered considerable insight with regard to the psychological profile of the chronic low back patient. Through the use of a multiple regression and correctional analysis, they studied the relationship between the neurotic triad of behaviors (hysteria, depression and hypochondriasis) and a number of independent variables including: age, sex, educational attainment, income diagnostic category, level of severity, number of surgeries and socio-economic status. Their findings are interesting and informative.

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The purpose of this article is the identification of the magnitude of low back disorders and the developmental and evolutionary bases of the human musculo-skeletal predisposition to low back problems. In addition, some very recent advances in the detection of potential low back disorders and the logically appropriate preventive measures will be provided.

The Cost of Low Back Disorders

Among the medical, safety and industrial relations specialists, there is consensus regarding the magnitude of the back disability problem. This disability must be categorized as an inclusive area comprised of disruption of production, costs of workers’ medical and disability payments and the “cost” of pain and suffering.

Some informative demographic data must be considered when constructing a foundation upon which a potential plan for prophylactic low back programs may be developed. In their landmark study, “Preventing Low Back Pain in Industry, Sparrell and McKeon report that low back pain is the cause of 20 to 25 percent of workers’ compensation cases. The cost of this compensation is more than five billion dollars annually and is on the rise.

Additionally, their findings suggest that male workers, in their 30′s and 40′s are four times as likely as their female counterparts to become disabled Interestingly, men in this age group comprise 46 percent of the total work force but account for 71 percent of lost time from work attributable to low back conditions. The highest rate of reported back disabilities are related to physically demanding jobs including, trucking, warehousing, heavy manufacturing and nursing (handling patients).

Preventive Techniques for Industrial Low Back Problems

Through the development of Low Back Schools and Occupational Therapeutic Programs, a number of preventive techniques have been proposed. Some of the categories which have been documented to be effective in reversing the job related incidence of low back disorders are: medical selection, worker and supervisor training and task analysis and redesign.

Each of these measures may be categorized as preventive in nature. However, each of these techniques provides distinctively singular disciplinary approaches to the same problem. When utilized in some combination either in clinical application or in developmental consideration, these components of preventive low back care exemplify the essence of the holistic approach to health related problems.

Medical Selection

As one of the initial risk appraisal procedures for low back disorders, a medical screening is suggested in the literature. Included in this risk analysis is a physical examination and review of medical history. Contributory elements which have been documented to be statistically relevant in the prediction of low back injuries are: past history of low back “episodes”, radiological evidence of spinal abnormalities and physical performance testing including strength and range of motion testing.

In addition to the aforementioned musculo-skeletal criteria, some form of psychological evaluation should be included in the medical selection portion of the low back screening process. The recommendations for psychological screening include: hypochondriasis, hysteria and chronic depression. The use of psychological pre-screening for the purpose of potential employment is quite complex with regard to the civil and legal rights of the prospective employee. The decision for employment suitability may be considered an infringement upon the civil right of the employee for equal opportunity and access to certain positions. In any case, the benefit of medical selection for objective risk appraisal regarding low back predilection is supported in the literature.

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Practice gentle skin care.
Avoid irritants like harsh scrubbing creams and exfoliators.
Avoid hot baths; use warm water.

Use emollients liberally. Note that creams are more lubricating than lotions.
Moisturize your body when you come out of the shower and you’re still damp.
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Avoid drinking alcohol. Keep your body dry and cool — avoid becoming overheated to prevent yeast infections.

See your obstetrician/gynecologist or dermatologist for any rash that causes discomfort or looks odd. Do not treat yourself.

You have a choice here, as do all women who experience bleeding on hormones. First, your doctor will determine whether the bleeding is anything to worry about. Often, if the bleeding persists for several months, we will look at the uterine lining with ultrasound or do a biopsy or D&C to make sure the bleeding is just a side effect of the hormones and not a sign of something more serious. If the bleeding is determined to be just a side effect, then you must make a decision: stop the hormones and lose all the wonderful benefits; hang in there and hope you are in the 80 percent of women whose bleeding will eventually go away; change to cyclic therapy and most likely have predictable monthy periods; or work with your doctor to adjust the dose of estrogen and progestin to try to stop the bleeding. The last option usually involves increasing the progestin component (with Prempro this would mean changing to Prempro-5), although sometimes estrogen doses are modified. It requires patience on your part and good communication with your doctor as well.

I would encourage you to talk to your doctor directly, via a face-to-face appointment, to discuss these options. In my opinion, for the vast majority of women, the benefits of hormone replacement are well worth the effort.

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A. First, let’s talk about why your doctor suggested hormone replacement therapy (HRT) in the first place. The most likely cause of death in women after menopause is cardiovascular disease. Use of estrogen in these women may reduce this risk by 50 percent — and if that is not amazingly significant, then I don’t know what is! Estrogen also reduces the risk of osteoporosis (brittle, easily broken bones) and Alzheimer’s. Hormones also help with menopausal symptoms such as hot flashes, night sweats and vaginal dryness.

Now, for the annoying little side effect you have noticed: some women who start hormone replacement will have bleeding. Medications like Prempro (a combination of the estrogen Premarin and the progestin Provera) are called “continuous combined” therapy because they deliver both the estrogen and the progestin component every day. With continuous combined therapy, 80 percent of women who stick with the hormones for a year will NOT bleed — however, in the initial several months of use, irregular nuisance bleeding is fairly common. Twenty percent of women on continuous combined therapy like Prempro will continue to bleed indefinitely.

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A six-year study conducted by Harvard University researchers found a relationship between a diet rich in tomato-based foods and a reduced risk of certain kinds of cancer.

Intrigued by those findings, Omer Kucuk, M.D., an oncologist at the Barbara Ann Karamanos Cancer Institute in Detroit, launched a small pilot study in 1999 to try to demonstrate a biological effect from eating tomato lycopene. He took a group of 26 patients with early-stage prostate cancer who were already scheduled to undergo radical prostatectomies (removal of the prostate and biopsy of the surrounding tissue). The group was randomized by computer and divided into two groups. The control group did nothing. Patients in the test group were given 15 milligrams of tomato lycopene in capsule form twice a day for three weeks prior to surgery.

After surgery, the removed prostates were examined.

Kucuk explained, “When we tabulated the results, the group on lycopene had smaller cancers, and their cancers were confined to the prostate. The cancers in the control group were larger and went to the margins of the resection, or even beyond the gland. We also found the precancerous areas were much smaller in the group that took lycopene.”

Kucuk says there are two possible explanations for these results. First, lycopene is an antioxidant that neutralizes free radical oxygen molecules before they can damage the DNA of cells. Lycopene is the most powerful of the antioxidants and is found in great abundance in the testicles and prostate.

But Kucuk says his study was probably too short to be explained by free radical action. Instead, he theorizes that lycopene may have had an anti-inflammatory effect.

“We are looking at the role of inflammation in the growth of cancer cells,” he says. “Inflammatory molecules promote cell cancer growth. If you can prevent inflammation, maybe you prevent the growth of cancer. Antioxidants like Lycopene inhibit the enzymes that cause inflammation and may be the reason the tumors in the test group shrunk.”

Kucuk and his team also followed the prostate specific antigen, or PSA, levels of both groups. PSA is a protein present in the bloodstream of men with prostate cancer. High levels of total PSA indicate a likelihood of cancer.

“We did PSA levels on all subjects at the time they entered the study and then again right before surgery. To our surprise the individuals who took lycopene reduced their PSA by 18 percent. In the control group it went up 14 percent.”

Although this study was too small to draw definitive conclusions, Kucuk is encouraged to repeat the study on a larger test group. He will also be conducting studies on patients with advanced prostate cancer.

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Kick athlete’s foot — wear socks that keep your feet dry.
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If you have chronic knee or back pain, try walking instead of running.
Before you buy walking or running shoes, try them on both feet.
Before you buy shoes, consider their cushioning, flexibility and support.

Make sure your shoes have leather or synthetic supports that prevent sprains or broken bones. Make sure there’s a thumb’s width between your big toe and the end of your shoe.

Buy shoes that fit and feel good when you try them on.

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