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WHY THE INTEREST IN NECK AND BACK PAIN?
It seems that everyone has suffered neck or back pain at some stage. Neck or back pain affects between 60% and 85% of people. Probably you are one of these people. In one study, researchers reported that 21% of patients experienced back pain in the 14 days preceding the study. Another study reported that at least 5% of all patient visits to the doctor are due to back pain.
Tremendous costs are involved. Neck and back pain account for half the worker's compensation payments in the United States and Australia, they are the single greatest cause of lost work time in both countries, and low back pain alone costs over $85 billion annually in the United States, about one-third of this amount being the direct costs of medical care. The 10% or so of patients who suffer chronic back pain account for 75% of Australia's rehabilitation and compensation payments. The social cost cannot be calculated back pain is the most frequent cause of inactivity among people under 45 years of age. In the U.S., Great Britain and Australia, the number of people disabled by these problems has increased exponentially since the 1970s, during a period of only modest population increase (Schwarzer, 1996; Rainville et al., 1996).
However, patients are not the only ones to suffer. Back pain has been described as "a wilderness across whose inhospitable terrain orthopedic surgeons, neurosurgeons, physiotherapists and, above all, general practitioners are doomed to travel" (Littler, 1983). Most doctors believe "there is little doubt that most cases are due to derangement of the intervertebral joint in association with 'degeneration'of the disc and arthrosis of the facet joints" (Ganora, 1984), or, as it was put more simply, "more than 95% of patients with low back pain suffer from mechanical back pain" (Schwarzer, 1996, p. 108). And yet an article in the New York Times about a study published in the New England Journal of Medicine raises serious doubts about these claims: nearly two-thirds of a group studied had "spinal abnormalities, including bulging or protruding discs, herniated discs, and degenerated discs" but none of the subjects in the study had back pain, or ever had suffered from this problem (Kolata, 1994).
What is this book about?
I have found that most neck and back pain is experienced in the muscles associated with the spine. The pain is caused by excessive tension held in these muscles and is the result of a variety of causes, from structural imbalances to various aspects of lifestyle. These causes can be treated. Except for a very small percentage of neck and back pain which can be dealt with successfully by surgery or drug therapy, I advocate a conservative, exercise-based approach, the subject of this book.
What can I do?
My approach to overcoming neck and back pain has two parts. The first step is to help you identify which muscles are involved in your particular problem and to teach you the most efficient ways to relieve this excess tension, using extremely efficient stretching exercises, initially to be done only twice per week. This phase of treatment the rehabilitation phase) is enhanced by teaching you how to use directed relaxation to assist the body to sleep and to enhance its healing tendencies.
The second step (the prevention phase) conditions all of the relevant parts of the body by using more advanced stretching exercises and later, by adding specific strengthening exercises, to provide a measure of protection for the future. In these two chapters, I shall present an approach to neck and back pain that is effective in practical terms and a later chapter considers the problem in theoretical terms, and will help you to make sense of the conflicting research on the problem.
Who should use this book?
This book is written for anyone who suffers recurring neck or back pain, or who wishes to avoid these problems. Recovery isn't quick or simple, but there aren't many other options either. Unless your back or neck problem is of the kind that can be treated effectively by surgery or drug therapy (probably less than 10% of the cases presented to general practitioners), you may have found that the range of options seems limited to avoidance of the activity thought to be the cause or treatment of the symptoms. If treatment is successful, your back will be returned to normal; that is, to its "preinjury" level of function consequently, there is no guarantee that the problem will not return. My aim is to present a unified and comprehensive self-help approach. For those fortunate enough not to have such problems, the approach will increase the suppleness and strength of your neck and back to reduce the likelihood of injury to these areas.
How this book is set out
The introduction sounds a more personal note than following chapters. It begins with a brief history of events which led me to my current approach, including a rather lengthy stay in Japan where I studied Shiatsu and a number of traditional exercise systems. I consider the various exercise systems from which I derived my own, the courses called Posture & Flexibility, and Strength & Flexibility, currently taught at the Australian National University. My clinic in Canberra (the Shoshin Center) is mentioned, and I present some relevant neck and back pain case studies. The first three chapters include the self-diagnosis method, and the stretching and strengthening exercises these are the nuts and bolts of my approach.
Chapter one takes you through the self-diagnosis step-by-step. There is a flow-chart of the diagnosis method at the end of the chapter, and a page to photocopy. On this you fill out the results of the leg length tests and the functional flexibility tests. Fill it in as you go through the chapter. There is also an illustration of where pain may be experienced in the neck and back, and exercises likely to be useful are listed alongside.
Chapter two contains the basic pain-relieving and rehabilitation exercises; the first section describes exercises for the back, and the second describes exercises for the neck. These are the most important exercises in the book, and for most people are the only ones they need to do on a regular basis.
Chapter three details the preventive stretching exercises. These are designed to improve and balance your existing flexibility, and allow you to focus more closely on your problem areas with stronger techniques. The second part of chapter three outlines my approach to strengthening exercise, and details a set of graded strength exercises, from a minimal set suitable for doing at home through to more elaborate exercises for which some equipment is needed.
However, do not go straight to the exercises without reading the cautions section below. Inappropriate exercise may worsen your condition, and the nature of the problem is the best guide to selecting the exercises which are right for you.
You will get more out of the exercises if you have a reasonable working knowledge of the anatomy of the areas of interest. For this reason, useful functional anatomical information will be found together with the exercises. Organizing the book this way means that you do not need to go backwards and forwards between the exercises and the anatomical details upon which the exercises so crucially depend. As mentioned, much experience has shown that the actual locus of neck or back pain tends to be the muscles associated with the spine. As each muscle has a clearly definable function, this knowledge will help you locate the particular group concerned, and guide you to the best exercise. The book has been bound so it can be left open on the floor beside you, to enable you to check your form as you practice, and the practical sections include Notes (presented in a larger typeface than the text) that contain the most important details about how to do each exercise. These are arranged alongside the photographs for easy reference.
Chapter four discusses the various causes of neck and back pain, from a number of medical perspectives beginning with that of western medicine. One of the reasons for so doing is that western medicine has the most detailed understanding of anatomy, and this knowledge is fundamental to my approach. Another reason is that we are familiar with the western medical perspective it is the medicine of our culture. This chapter includes a brief consideration of chiropractic and osteopathy because neck and back pain is the main concern of these practitioners. Oriental medicine and some of the bodywork schools are also considered. Acute and chronic pain are treated separately, and mention is made of additional contributing factors. The chapter sounds a note on the limitations of the very idea of cause with respect to common illnesses, and offers a rationale for my functional approach. The experiences of the workshops we have been running for individuals and practitioners are presented, and consideration is given to choice of beds and pillows.
Chapter five provides a justification for including relaxation techniques as part of the larger approach to overcoming neck and back pain. It discusses practical stress management briefly, outlines the current understanding of stress and its effects on the body, and ends with an easy-to-learn method for relaxation. Useful guided visualization techniques for speeding up the heating process are included in the relaxation script.
Before you begin, some notes of caution must be sounded. If you are undergoing some form of treatment at the moment, you must discuss the exercises presented in the book with your practitioner before beginning. It is a matter both of courtesy and safety some of the exercises may be inappropriate for your condition. Further, embarking on a course of exercises that have not been examined or approved by your practitioner may void any compensation to which you may be entitled. I have written this book in good faith, but I cannot personally supervise your performance of the movements, and therefore cannot accept any responsibility for errors you make. Neither can I know the particular details of a condition you may have this is your responsibility. These aspects necessitate the greatest caution on your part the fact that thousands of people have benefited from this system is no guarantee that you will. Consequently you must approach the exercises with caution, and you must monitor the effects closely.
Next,do not refer only to the photographs. You must read the sometimes lengthy descriptions that accompany them. Information vital to safety is contained in the text, along with descriptions of how to press or pull certain parts in certain ways. It is not possible to understand the exercises only by looking at the photographs.
The next caution concerns the order in which the exercises are presented. In most cases the easiest and safest versions of any movement are shown first; these versions are marked easiest in the text. More difficult versions are labeled intermediate; the most difficult are labeled advanced. This is the order in which you should attempt them. Even if you know that you can do a more difficult version, begin with the easiest one. You can always learn something about the way your body works from doing an easier rather than a more difficult version of an exercise, simply because you can concentrate more on your responses to a movement rather than its complexities. Additionally, the easier versions are a useful warm-up for the later ones.
Lastly, I wish to discuss some practical cautions. Exercise in the evenings rather than the mornings as the body is more supple then. You must not exercise within an hour and a half of eating. It is best to exercise in the hour before you eat the evening meal. Always go to the toilet before beginning. Wear clothing that both keeps you warm, and permits free movement. Some of the exercises require a strap, strong towel, or some other method of holding a part of the body, so have something handy. For the first few weeks or months, I suggest that you stretch only twice a week, which may be increased to three times as you improve. The text includes specific instructions on the few exercises I recommend be done daily to relieve the body of the effects of the day's stress. More of this later.
The following caution may be self-evident, but permit me to labor a vital point. You must imitate the form of the exercises demonstrated, not my performance of them. The purpose of the precise descriptions and photographs is so that you can place yourself in the positions I have found to produce the best results. You then proceed with the stages of the movements only until you feel the stretch I describe, and stop at that point. In the demonstration of the movement, I may have taken the particular limb further in the range of movement than you can, but this is immaterial. (You may well be able to stretch further than I in some exercises, too.) The sole purpose of an exercise is to feel a stretch in the right place. Please keep this in mind most teaching of stretching exercise fails on this crucial point.
The most general, and important, caution I have saved until last. It is that you must listen to what your body tells you while you are doing the movements no one else can do this for you, not even the best teacher. Very early in your practice you must learn the essential difference between the right kind of stretch sensation and going too far. For this reason, I urge you to do too little rather than too much in the beginning realizing the difference too late will be painful, and possibly dangerous. Remember the old adage: "Rome was not built in a day."
The Introduction provides you with the background to the approach advocated in the book. If you prefer, you may go straight to chapter one, the self-diagnosis method, and return to the Introduction at a later time.
BACKGROUND TO THE APPROACH
In this introduction, I should like to give you some personal details, which I hope will both be interesting and give you some insight into what led me to develop the methods presented in the rest of the book.
During the early 1980s, I was a television director and a struggling athlete. I trained for the 800- and 1500-meter races, the so-called middle distance events. Directing the Australian Broadcasting Commission's nightly current affairs program Nationwide was stressful enough on its own; together with all the running training we ran 100 miles (160 km) a week in the winter months I now think that I was asking too much of myself. I used to hold a tremendous amount of tension in the middle back muscles. Despite physiotherapy and chiropractic treatments, the problem never really improved beyond temporary relief.
Some sort of insight occurred one day when I bent down to touch my toes after an interval training session at Sydney University. At full stretch my fingers came a few inches below my knees, and that was with my back bent like a bow. Someone took a photograph of me doing this, and it ended up on the wall at the H. K. Ward gym (where many of the local track and field athletes did their weight training), suitably inscribed "Rubber Man."
The next insight occurred when I was using the seated heel raise machine (from the seated position a padded bar over the knees is lifted by the feet to strengthen soleus, one of the two calf muscles). I placed my feet evenly on the footrest and positioned my heels level with each other. One knee contacted the support bar. The other was a full centimeter or so lower. Naturally, my first thought was that the machine had been bent by one of the serious bodybuilders using too much weight. I looked at it carefully, got a tape measure from the attendant at the front desk, and after careful checking decided that it was straight. Only then did the possibility that I might not be straight occur to me. Careful measurement revealed that my right leg from knee to heel was noticeably shorter than my left. I mention this only to highlight the point that we resist the notion that there might be something less than ideal in our own physical makeup, but consideration of all possibly relevant information is essential if we wish to overcome our problems.
Once I had accepted the difference (in fact my right leg is shorter by about three quarters of an inch or two centimeters, evenly divided between the upper and lower leg), I began to think about the effects this structural asymmetry might have caused. I had trained for both Olympic and power lifting for years before losing quite a deal of weight to become a middle distance runner. I realized that years of weight training adapted my body to two major stresses the stresses of the training itself, and the asymmetric distribution of those forces as resolved in my particular body, so not only had I become extremely tight in the process but had also developed an individual pattern of flexibility. I began "limber" classes at a Sydney dance studio, and these patterns became only too clear. I also quickly realized that the approach adopted in these classes was not efficient for teaching adults how to become flexible. The young students were very supple and had become flexible while they were still children. What looked like stretching classes were really preparation, or an extended warmup for their ballet classes later in the day. My experience there made me think about the differences between adults' and children's bodies, and how one might improve on the standard approaches to the problem of how to teach adults to become flexible.
At this time, I experimented with lifts of various thicknesses in my right shoe. The difference it made to running was immediately apparent. The shooting pains in between the shoulder blades experienced in the finishing stretches of my races all but disappeared, and on using the insert the first time, I immediately felt more balanced walking and running.
During the late 1970s I attended yoga classes at various places around Sydney. I found the classes relatively inflexible in their teaching approach: students lined up in neat rows and little dialogue. The strict atmosphere often discouraged questions at the very time one needed assistance. I was disturbed by the tendency for some teachers to accept the pronouncements of their own teachers uncritically. Guru worship was commonplace, and many teachers had adopted the mannerisms and aphorisms of their own gurus. What I subsequently learned to be the correct form of various poses was being distorted by many students in their attempt to imitate the teacher through simple inflexibility. Questions like, "why do we do it this way?" were left unanswered, or deflected with replies like "tradition," or "that's the way the posture is taught by my teacher," and so on. I met few teachers who had more than a passing acquaintance with anatomy the one aspect of western medicine normally unquestioned by the alternative healing arts. Of course, these were my particular experiences at the time; much has changed since these early days, and anatomical knowledge is now emphasized in contemporary yoga teaching.
During this period I also resumed martial arts training, and so did the kind of stretching usually employed in these arts during the warmup vigorous dynamic movements, assisted by a partner or an instructor, and all over in 15 minutes before the real training began. No attention was paid to form in the exercises, and I injured myself a number of times using this approach. On one occasion, I pulled a groin muscle (one of the adductors) that took nine or ten months to heal and which was subsequently injured at another training session.
I had my thirtieth birthday in Japan. I had had enough of television, and decided to go to the source for martial arts. I was dismayed to find the same approach to stretching used there too. I found disbelief on the part of teachers who could not accept that someone who had trained for ten years or so was not perfectly flexible. They had no effective suggestions on how to become more flexible. They had all done the usual stretching as children (usual in Japan, anyway), started their martial arts training at an early age and consequently did not need to know how to make an adult flexible. The severe training I went through (I was a live-in student, called an uchi deshi) made my back muscles even tighter. After nearly a year and a half of this life, I found myself unable to recover from an illness that alternated between a cold and influenza for six months. A friend had been studying a form of oriental medicine for a year or so (shiatsu) and, sick of being kept awake at night when I visited, he suggested that I go to see his teacher.
It was a revelation. Never have I let anyone hurt me so much. I was holding a tremendous amount of tension in the muscles of my body, and all the places he worked on, including my back, were incredibly tender to touch. The sensei told me that although my body was strong it was holding excessive tension everywhere, which he felt was the result of the stress of the work I used to do plus the effects of the rigorous current training. He would poke my body and say in English, "Too hard, too hard." I confess I was skeptical of a treatment that consisted merely of maintaining a leaning pressure on various places using the elbows and thumbs mainly, together with a few simple stretches and manipulations of the bones of the body. However, I started to feel better that same day, and by the time of the next treatment (a week later) the cold had gone. It was at the conclusion of the second treatment that I was introduced to a woman who would change my way of thinking about flexibility. Ms. K was a diminutive Japanese woman around 35 years old. She was the translator for the shiatsu classes presented for foreigners at the center. Sensei mentioned that I was interested in becoming more flexible. Ms. K's way of getting to the floor for this conversation involved sliding through the side splits into front splits, then lifting herself into seiza, the normal Japanese way of sitting on one's feet. It certainly got my attention.
Ms. K and I were to do considerable work together during the ensuing few years on flexibility and shiatsu, as I became a student. She was the sole surviving shihan (senior teacher) of an exercise method called Jikyo Jutsu. Roughly translated, this means "self-help method." Like Tai Chi, it is based on meridian theory, the practice of which is designed to "harmonize energy flow" around the body and promote internal health, in much the same way as shiatsu. This improvement in internal health is said to be responsible for the increase in flexibility that follows. In other words, the acquisition of flexibility was deemed to be a side effect of health. Quite different to our western approach, I thought. The exercises themselves were an interesting mixture of dynamic stretching movements and pressure point therapy. In time I was awarded a shodan (a "first degree" black belt). "Sho" is the character for "beginning," and unlike other parts of the world where a black belt is often regarded as a pinnacle of achievement, in Japan it signifies a starting point.
Part of the learning process of shiatsu involves receiving treatment from one's teacher. I received treatment for a year or more on a fortnightly basis, did the Jikyo Jutsu, and taught and attended yoga classes in Tokyo. By the time I had been in Japan for three years or so, my back felt considerably better and my flexibility was noticeably improved, particularly when I cast my mind back to the "Rubber Man" era. All was progressing, I felt. An incident one day on my way to teaching a stretching class at the well-known "Clark-Hatch" gym in Tokyo soon dispelled my complacency. While walking across the car park (thinking about something else), I inadvertently stepped off a low curb no more than three or four inches high and felt a stabbing pain in my lower back. The sensation was so strong it literally took my breath away. I continued walking to the gym, and although my back did not feel "right," I taught the class. When I returned home that evening, I stripped off and looked at myself in the full-length mirror in the bathroom. Unbelievably, my hips seemed displaced so much to one side that the normal indentation of the waist had completely disappeared on one side, compensated for by double the amount on the other. I had trouble accepting the evidence of my eyes; I could not believe what I was seeing.
The following days suggested that this distortion was going to be with me for some time. I had treatment variously from my shiatsu teacher, a well-known local chiropractor, and in desperation yet another shiatsu teacher. None altered the displacement by any extent that I could see or feel. Worse still were their claims that they had not seen any equivalent problem in all their years of practice. I was so worried by this that I travelled four hours north of Tokyo to a famous chiropractor, but he could not help either. Very slowly, with careful stretching over a period of seven or eight weeks, my shape returned to normal. I now think that the incident resulted from an imbalance of too much flexibility and not enough strength, my body being predisposed to certain types of injury due to my leg-length difference.
I spent considerable time thinking about the physical structures involved. One chiropractor suggested that the distortion resulted from one hip bone (the ilium) moving with respect to the sacrum (in effect, driven upwards by the unexpected force of stepping off the curb onto my shorter leg while completely relaxed). This joint, particularly in men, is normally stable, the ligaments binding the sacroiliac joints on both sides of the pelvis are extremely strong, and the internal surfaces of the joint are irregular and fit each other. It is possible that all the hip abduction work (legs-apart stretching) I had been doing had upset the stability of the pubic symphysis (the joint where the pubic bones come together at the front of the pelvis), thereby permitting the much more stable sacroiliac joint to move. However, because the shape of the distortion appeared simply to be an extremely exaggerated version of the normal lateral curve in my lumbar spine induced by my leg-length difference, I thought this unlikely. Another chiropractor thought that my pelvis had "rotated" with respect to the lumbar spine, and that was the cause of the problem. When my teacher suggested that enough shiatsu treatment would even up the length of my legs, I felt that I needed to consider the problem in depth.
The apparently conflicting explanations I had been offered for the problem led me to think about possible relationships between information produced in different frameworks, and about standards of evidence. It seemed to me then (and seems so today) that there are various kinds of facts about the world, and that there are different expectations of reliability in relation to these facts. "Information" or "facts" depend crucially on the assumptions underlying the different frameworks giving rise to them, and these facts come bound together with indices of reliability. In this sense there are no certain facts (we might say, though, that some facts are very reliable and others less so), but comparison of explanatory range, assumptions, reliability indices and suitable constraints permit evaluation of different kinds of facts. In respect to my back problem, for example, it was not that one perspective was wrong and another right. Each perspective provided one window on the problem a window that revealed a particular view.
These musings led me to think that, in respect to a health problem, we might conveniently divide the body into psychological and physical aspects for particular reasons, as western medicine ordinarily does. For example, the physical body might be considered in terms of a spectrum, from its least-alterable to most-alterable substances, as one way of deciding how to tackle a problem. One advantage of working with the physical aspects of a body (in contrast to the psychological) is that some of the cause and effect relationships are better known, and are often measurable. For instance, we know that the nerves of the body react most quickly to stress, followed shortly after by the muscles, then ligaments and tendons, and the slowest to change are the hardest substances in the body the bones and teeth. How these substances manifest their reactions to particular stressors is well known. Knowing this about the body's organization, in respect to a problem like neck or back pain, we may affect the brain and the nerves using relaxation techniques, we may affect patterns of muscular tension, the results of stress, by using the stretching exercises, and we can strengthen the body in various ways against expected future stress.
This simplified approach may seem like a structural and engineering analysis, but the oriental medical "umbrella" permits useful association of aspects of the problem whose precise causal relationship is not clear. The oriental perspective allows greater freedom than the western medical approach, because it is a medicine of correlation rather than cause it is a system of correspondence (Porkert, 1974). I will discuss the problems of causality further in chapter four. The essence of my approach is that, in respect of multicausal problems, analysis and treatment is better directed towards a desired outcome rather than trying to solve the problems of causality. This approach can avoid the pitfalls of symptomatic treatment.
In 1988 I opened the Shoshin Center, specializing in shiatsu. One of the four main forms of oriental medicine in the modern world, shiatsu applies periods of still, manual pressure on the acupuncture points for treatment following the yin-yang and the five element (or transformation) theories. Shiatsu was developed in Japan around the turn of the century by joining aspects of the Palmer chiropractic method with traditional Chinese massage, called anma in its Japanese form. Although I opened my center with the intention of practicing preventive medicine, the majority of patients were seeking a cure for a particular problem affecting them at the time. Although I stressed the medium and long-term effectiveness of lifestyle modification and the application of specific exercises for their problems, most patients preferred to return at three- or six-month intervals for treatment. By the end of the first year, it was clear that most patients wanted help with neck and back pain more than any other problems, and this pattern has continued to this day.
At any initial consultation in my clinic, I state that we should both know after a treatment or two whether my approach is likely to be effective, and I stress that any recommended exercise is an integral part of the treatment. It is essential to the success of any treatment that patients take responsibility for their problems. Most patients are agreeably sur