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Back Care and Back Pain

In September 2009, our guest expert was Dr. E. Laura Cruz, a sport medicine physician on staff at Women’s College Hospital’s Sport CARE program and at St. Joseph’s Health Centre.

Dr. Cruz is also co-owner of Pivot Sport Medicine and Orthopaedics, past chair of the Women’s Issues in Sport Medicine Committee for the Canadian Academy of Sport Medicine, and a faculty member at the University of Toronto. She has served as team physician for local, provincial and national sport organizations as team physician, working with athletes in fields ranging from ballet and gymnastics to hockey and skating.

Her sport medicine interests include injury prevention, promoting physical activity, concussion awareness, the Female Athlete Triad (disordered eating, amenorrhea and osteoporosis) and topics related to healthy active women, such as exercise and pregnancy, stress fracture prevention, osteoporosis and osteoarthritis.

Her patients are of all ages and include amateur to elite athletes, performers and dancers, coaches, pilates and yoga teachers, active individuals and those wishing to become active.

Here are her answers on Back Care and Back Pain.

Q: I was at work when I leaned over my desk to sign something and my back locked. I could not move. Then I felt something scrunching in my lower back and my back unlocked. My family doctor told me it was from the ligaments in my lower back. How does something wrong with ligaments cause my lower back to lock? He also said that there is no way to prevent it from locking. But he did say to stretch it. Do you know of anything I can do to stop it from locking?

A: There are several structures in the lower back that can feel ‘locked.’ Muscles may contract to protect the deeper structures and are often the cause of the locking. Pain will also make us feel ‘locked’ and can arise from a variety of structures. The fundamentals of good back care include caution with postures that over-stretch supporting muscles and ligaments, stretching out the tight anterior or stomach muscles plus optimizing back and ‘core’ muscle strength. Those core muscles are the sheets of muscles that include the abdominals, but also the deeper muscles that wrap around the trunk to help support us in various postures.


Q: Can you explain the term ‘slipped disc?’ Is it an accurate description? I heard that the disc doesn't actually slip. What does happen and why? I injured my lower back several years ago at the gym when I twisted around quickly to pick up a heavy weight. I felt a very sharp pain in the centre of my lower back, and then acute pain. My doctor prescribed physiotherapy. My physiotherapist explained the injury had something to do with the discs. I needed physiotherapy and exercise to regain my lower back strength. I am fine now. 

I try to do exercises to strengthen my back, but can you also recommend some lower back exercises to keep the back healthy?

A: You are absolutely correct that we do not actually ‘slip a disc.’ We do however injure the disc to different degrees, some of which are described as ‘slipped,’ or ‘ruptured’ or ‘herniated.’  Exercises to protect the discs usually include strengthening the abdominal and trunk muscles. There are numerous excellent ways of achieving this: Pilates, exercise ball workouts and yoga are a few.


Q: Can you recommend specific treatment (including exercises) for pain related to facet joint problems?

A: The facet joints are the small joints of the back that allow us to bend and twist. Like any joint, they can be strained or wear down. Exercises to help with facet joint problems, like those for other back-related pain problems, include strengthening the core muscles; achieving good neutral posture in which the back is not overly arched, and using sitting and lifting postures that support this. Pilates and yoga training include appropriate exercises.


Q: Why is there such a poor relationship between medical doctors and doctors of chiropractic? At the age of 20, medical doctors had me on narcotics to control the pain in my back and hips. After regular chiropractic, I take no medication outside of the occasional aspirin. I am now 45 years old. I have osteoarthritis in my hips, but am not in a wheelchair thanks to my chiropractor.

A: I am very pleased that your back and hip pain have been managed such that you need only occasional pain medication. Historically, interprofessional understanding between medical doctors and doctors of chiropractic has not been ideal, but great strides have been achieved by many disciplines in health care to improve this.

Manual therapy, such as that provided by chiropractic care, is now recognized as an important component of treatment for back and joint problems.


Q: Three years ago I herniated four discs in my back. I have tried chiropractic, laser therapy, acupuncture, physiotherapy and massage therapy. I have had a facet block and two epidural blocks all in the hope of helping to relieve the pain, tingling and numbness. I have exercises that I do every day and I am still attending physiotherapy and massage. I have had two MRIs which show moderate degeneration, spinal stenosis and the disc herniations.

My doctor has referred me to three different orthopedic surgeons, but all have refused to see me, the last one saying that surgery is not indicated.

I am only 55 years old, and live with this pain and discomfort on a daily basis, some days worse than others. I have had a few instances where I have had to be off of work for several weeks because I was unable to walk or sit.

I cannot walk for long periods of time, and my physiotherapist has changed my program a few times, trying different techniques to see if anything would change, but nothing ever changes.

Do you have any suggestions? I am afraid that I will soon end up in a wheelchair.

A: Unfortunately, many individuals suffer daily pain as you are experiencing. Having a combination of stenosis and disc degeneration is a therapeutic challenge, as you know. Research has suggested that a comprehensive team approach may be best, but it is recognized that this is not always available in a timely fashion and is usually only offered in tertiary care teaching centres.

Surgery may not be offered to you because the outcome may not in fact improve your symptoms – only your X-rays and MRIs.

As with many back disorders, being as fit and strong as you can possibly be may be helpful. The use of medications, nerve blocks, therapy and periodic rest may still be necessary.

You may also benefit from additional skills such as mindful meditation and yoga (albeit modified) or osteopathic therapy.

I would suggest reviewing your treatments and responses to date with your family doctor and exploring whether or not a referral to a multi-disciplinary pain clinic would be of benefit to you. This may be a ‘double’ appointment, so check with your doctor’s office about that to ensure you have adequate time to discuss things.


Q: Do you have any suggestions for the treatment of camptocormia (forward flexion of the neck and upper back)?

A: The causes of camptocormia are varied and so the treatment must be tailored to the specific cause in any given individual. Depending upon the underlying cause, treatments such as anti-Parkinsonian medications, Botox injections and deep brain stimulation surgery may also be helpful. However, the utility of any of these treatments must be assessed on an individual basis.


Q: What do you recommend for improving one’s posture?  I have rounded shoulders and would like to stand up straighter, but I just don’t seem to be able to. 

A: Achieving improved posture is like learning to like olives – it has to be worked at! In achieving new habits, there is a period of conscious effort followed by a longer interval of automatic adaptation. Using visual or sound cues, such as Post-it notes or alarms on your cell phone or computer may be helpful to remind you to ‘sit up straight.’ Using your chair back to support you and trying to be as tall as you can are easy ways to improve posture. Keeping your elbows at your side, just behind your hips will be a big help in achieving improved posture. Occasionally, therapists will use taping to remind shoulder girdle muscles to keep working even when you are too busy to remember.


Q: I have had two emergency back surgeries for herniated discs (L4, 5 and L4, S1) in 2001 and 2004. I was a recreational athlete in my teens and my twenties and I miss doing some of the things I did prior to my back operations. I was told by my neurosurgeon to swim but stay away from impact sports. I certainly would not go back to rollerblading or playing volleyball. However, I would like to play tennis again. Dr. Cruz, what are your thoughts about this dilemma?  Thank you for your time.

A: Your neurosurgeon is trying to spare you from further problems with your back! Many individuals with disc problems such as yours hope to return to prior activities and some do so, with success. However, activities that put the back into a flexed or bent forward position or include jumping or landing are often discouraged. Having a frank discussion about your goals with your surgeon and a qualified physiotherapist may be helpful.


Q: I lifted a heavy box the wrong way 15 years ago. Ever since then my back has gone out every few months. Is there anything I can do about it or do I have to just live with it?

A: Fortunately, your back going out and your symptoms of 15 years ago may not be from the same problem. Being in really good physical shape, being strong and being careful will be great ways to minimize your symptoms. It will take work and effort on your part; some time and money with an excellent therapist may be needed, but well worth the investment in the long run!


Q: I’ve had back pain on and off for 10 years. I have a busy, stressful job, don’t have time to exercise and am overweight. I’d rather take pills for the pain than go to a chiropractor or physiotherapist but my family keeps bugging me to go. What do you think? Are pain pills a reasonable choice for someone in my position?

A: Treating a back problem with pain pills may work, but for a short time only. Pain awareness is a complex process in the brain and body, and treatments directed only for pain are often short-lived in their benefits. Your back pain may be your body’s way of telling you that you are working too hard, and that being inactive and overweight is not OK. Your body may be asking you to use it more often in the way it was designed – with a more physical lifestyle!

Try introducing physical activity in a gentle fashion such as incorporating a few exercises when you wake up each day or before going to bed each night. Use weekends to go for 20- or 30-minute walks to add to your physical activity for the week. Gradually increase the walks to four or five times per week.

Take baby steps as you introduce more fitness activities into your life. In a short time you may find that your back pain has decreased and that you are less stressed and more energized than before for those long work days. Added benefits of improved blood pressure, blood sugar levels, and cholesterol, as well as reduced risk of many cancers, will be additional rewards.

Q: I have chronic back pain. I’ve seen ads on TV for spinal decompression. How bad does my back have to be before I'm a candidate for that? I’ve heard that it's an alternative to back surgery, yet I'm not bad enough to be a candidate for back surgery.

A: Spinal decompression is a concept that has been used in therapy clinics for a long while for disc- or facet-related back pain syndromes. The ads being aired on TV are usually for ‘high tech’ traction machines that ‘stretch’ you out on a regular basis and are accompanied by abdominal strengthening exercises. So, they are often quite successful at decreasing symptoms for a time. However, they do not replace appropriate conditioning and strengthening exercises, nor do they claim to do so. There is little evidence that these machines are effective for other kinds of back pain.

Q: I am 53 years old. Two years ago my family doctor diagnosed me (by X-ray) with L 3-4 degeneration of the intervertebral disc. How can I help myself? Should I have a preventive check-up with an orthopedist? Thank you for your response.

A: Thank you for your question. You do not say why you had the X-ray in the first place, so I will assume that you were experiencing back pain. However, degenerative changes as seen on X-ray may be found in individuals without symptoms. But the presence of symptoms implies that the support systems for the back are not optimal, so your goal might be to improve upon this by exercising in a manner that strengthens your trunk and back muscles. If you have no symptoms two years after the X-ray diagnosis, then you may already be fit and taking care of your back, or you are fortunate enough to still have a ‘healthy’ back despite the X-ray findings. Consider improving your back and core strength by taking Pilates or yoga classes, maintain close to ideal body weight, and improve your overall fitness. A referral to a good therapist or experienced fitness professional will help you more at this stage than a referral to an orthopedist.

Q: I have back pain due to fibroids and I regularly go to physio, but I am not noticing any improvement. How do I get rid of the pain?

A: Gynecologic causes of back pain are common and do not always respond to physical therapy. Being fit and strong may help, and there is a large body of research that suggests that exercise is a helpful strategy to decrease gynecologic pain. Be sure to review alternatives with your family physician or gynecologist and be sure your therapist has considered sacro-iliac or pelvic floor causes of your pain. If gynecologic treatments are not indicated, osteopathic therapy is often helpful when gynecologic causes of back pain do not respond to mainstream physical therapy.


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