Back Care

This handout outlines some general rules for caring for your back and provides you with ways these guidelines can be applied at home in day to day living. It should be read more than once. Invite your family to read it too. It is very helpful to discuss the information with your physiotherapist or occupational therapist to answer any further questions. The advice contained in the handout is of a general nature and it is important to apply it to your individual situation with professional guidance.

Back pain is one of the most common conditions affecting nearly all adults at some stage of their life. Pain in the back can come from damage or irritation to any of the structures in the back joints, muscles, tendons, ligaments, nerves, discs and bone. Fortunately for most people the injury and its problems are short lived and after it heals they return to normal. However, for others the injury is more severe and its effects are long-lasting. Back pain can affect all parts of your day, not just the times when you are active at work or at home.

Anatomy

Your back consists of a series of bones (vertebrae), discs, spinal cord and nerves, soft tissue including ligaments, muscles and tendons. The vertebraesit one on top of the other and are separated at the front by a cushion-like structure called the disc. The spinal cordpasses through the vertebrae in a protective passageway called the spinal canal. From the spinal cord, nerves pass away from the spine through small gaps on the side between adjacent vertebrae. The nerves to the arms come from the neck, and the nerves for the legs come from the lower back. These are the peripheral nerves.

The peripheral nerves act like telephone lines, taking messages from the brain to the muscles of the body, instructing muscles to contract, thus allowing us to move. They also carry information from the body back to the brain; providing it with sensory information about temperature, touch, pressure and pain. Bladder and bowel function is also controlled by nerves from the lower back. The best known of these nerves is the sciatic nerve. It is made up of several nerve roots and travels from the lower back, through the buttock, down the back of the leg and into the foot. Sciatica is the inflammation of one or other of the nerve roots making up the sciatic nerve.

Back Pain Cervical Thoracic Lumbar Sacral

Disc Injuries

The peripheral nerves can be irritated by pressure from a damaged disc. The disc is designed to act like a rubber washer, cushioning movement and allowing the spine to move in many directions. If it is damaged it can protrude and press against one of the nerves, which passes into the arm or the leg. A common term for this is “slipped disc”. The disc does not actually slip. It is made up of a very tough outer covering with a thick, jelly-like centre. If the outer cover is damaged, the jelly-like central substance tends to protrude. The “jelly-like substance” can then put pressure on the nerve root.

Healing of Back Injuries

Good blood supply is essential for the repair / healing of damaged structures and for removal of waste products. The bones, ligaments and muscles of the back have a good blood supply, so they can heal reasonably well. The problem is that they usually heal with a special type of tissue called scar tissue, which is strong, but not as flexible as normal muscles, ligaments, etc. Discs, however, have a poor blood supply and this often results in slower healing. Discs, therefore may be more easily damaged if care is not taken to prevent this. The most common type of injury to the back is to the soft tissue ? the muscles, tendons and ligaments. Most of these soft tissue injuries heal well, and this is why most people with back injuries recover.

Back pain is not visible to others. As such it is sometimes difficult to understand the problems that a person with back injury has to live with daily. To help yourself, it is important to keep as mobile as possible and learn how to move your body to prevent strain on your back.

Pain Relief

While in Hospital: Pain relief will be prescribed by your doctor. It may be ordered either on a regular scheduled interval or only when you have pain. In either case, it is important that you tell the nursing staff if your pain persists.

On discharge: Pain medication e.g. Panadol, Panadeine Forte etc may be taken as prescribed for pain. Remember, if there was pain in the arm or leg prior to surgery, it is not uncommon for twinges of pain to occur for up to a month following your operation. Numbness/ pins and needles are usually slower to recover and there may be some residual numbness.

DO NOT take any medications, particularly anti-inflammatories unless you have spoken to your doctor.

Log rolling and Getting in/out of Bed

Log roll (e.g. to your right)

1. Lying on back, bend left knee and place left arm across chest.
   
2. Tighten your abdominals, and
   
3. Log roll all in one movement to the right, keeping your shoulder and hip in one line, trying not to twist.
   
4. Reverse for rolling to the left.
   
5. Always move as one unit, like a log.

Getting In/Out Of Bed

Getting out of Bed

1. Log roll to your side (e.g. right)
   
2. Bring your knees and feet to the edge of the bed.
   
3. To sit up, push down through your left hand and right forearm/ hand.
4. Lower your legs over the bedside at the same time. Sit on the side of the bed long enough to ensure you are not light-headed.
   
5. Stand up by pushing through your hands. Brace your knees and your abdominals so you are well supported. Keep your head up as you stand.

Getting into Bed

1. Ensure your bottom and back of your legs are touching the bed.
   
2. Bend your knees as you feel for the side of the bed with your hand.
   
3. Sit on the side of the bed.
   
4. Commence side lying by lowering your head and support yourself on your forearm and opposite hand. At the same timeraise your legs onto the bed.
   
5. Bend both knees and tighten abdominals to roll onto your back.

Lying and Sitting

Lying on your back puts the least amount of stress on your spine. However it is important to be comfortable when sleeping. Your mattress should be supportive yet comfortable. A firmer mattress is best for most people.

• When you lie on your side, it is best for the knees to be slightly bent. You may like to lie with a pillow between your legs. Keep a single pillow under the head, thick enough to fill the gap between the point of the shoulder and the ear, keeping the spine in a straight line.
• When on your back, use a single pillow to support your head, making sure it is not too high. A pillow should keep the head in line with the spine. You may find a pillow behind the knees aids comfort.
• Do not attempt lying on your stomach until your doctor says you can.

Lying Down

Sitting

Sitting places the greatest stress on the spine. Avoid sitting for prolonged periods. It is important to move and gently stretch every 20 - 30 minutes, particularly when travelling in a car.

Your knees should not be higher than your hips when sitting. This ensures that you are maintaining the spine's natural curves. A firm chair with a straight back and solid full length arms is best for good sitting posture.

To achieve a better sitting posture, consider the following:

• Sit back in the chair so you can use a back support. If the seat of the chair is too long for your legs you will slump forward.
  
• Your feet should rest flat on the floor.
  
• Arm rests can be used to take some pressure off your back.
  
• For a better back support, you can place a rolled up towel in the small of your back approximately at waistline. Commercial backrests can be purchased from your occupational therapist or your local chemist.

Sitting

Standing

Stand with your feet shoulder width apart. Knees straight but relaxed. Abdomen held in comfortably. Shoulders back, but relaxed and chin tucked in comfortably.

Advice:

Wear supportive low heeled shoes, preferably with cushioned soles. High heeled shoes alter your centre of gravity and increase stress on muscles and ligaments. When standing for prolonged periods alternatively place each foot on a foot stool or telephone book. Stand to cough or sneeze if possible.

Standing

Lifting and Handling

Incorrect lifting and handling can result in injuries. Muscles and ligaments can be strained, and discs can tear. Often a back injury is a result of years of abuse and of incorrect lifting and handling. The final act which causes the injury may be as simple as bending over to tie a shoelace.

The most common area for back pain is the lumbar (or lower back region). If you lift an object incorrectly, you can exert pressure far greater than the weight of that object on your lower back. Most of us relate lifting to work or industry, but lifting occurs all the time, even when changing positions, e.g. sitting to standing. So it is important to know how to lift correctly.

Steps to Safe Lifting

1. Get a firm footing. Place feet shoulder width apart.
   
2. Bend at the hips, knees and ankles, but not your back.
   
3. Brace your abdominal muscles to support your back.
   
4. Use the muscles in your legs to lift. They are much more powerful than your back muscles.
   
5. Keep your head and shoulders up and move smoothly.
   
6. Keep the load close to you to minimise stress on your spine.
   
7. Never twist with a load. Use your feet to turn towards your destination.
   
8. If the lift is heavy, do not attempt to lift alone.

Always seek assistance. If you are lifting with someone else it is better that they are of a similar height. Make sure you co-ordinate the lift by lifting on the count of three.

Safe Lifting

Managing Daily Activities

Personal Care

Energy Conservation

After back surgery, you may find you fatigue more easily and it is important to pace yourself. Organise your schedule (i.e. try to space your activities throughout the day, alternate light and heavy tasks). Rest before you get tired. Have short rest breaks in the middle of a task and between tasks. Do not feel guilty about your rest breaks. Use assistive equipment where needed to avoid unnecessary bending and twisting e.g. long handled brush and dustpan. Eliminate unnecessary motions and tasks. Organise work areas to eliminate bending and overhead reaching. Allocate difficult tasks to others e.g. carrying shopping, vacuuming. Please consult your Occupational Therapist for more advice on your individual needs. If return to work is an issue, the Occupational Therapist is able to assist with this. There are many agencies within companies and in the private sector that are able to support your return to work. They can perform site visits; liaise with employers, vocational retraining etc.

Showering

A shower is preferable to a bath. You may require a shower chair. If you don't have access to a walk-in shower, use a bath seat and a hand held shower.

Sitting down to dry yourself may be helpful. Aids such as soap-on-a-rope, a long handled washer, or a soap mix help to reduce bending over while washing.

Grooming

Whilst at the mirror/ sink it may help to put one foot up on a small stool to ease the load on the back.

Grooming

Toileting

Getting on/ off low surfaces may cause back strain. Whilst in hospital, you can trial an adjustable height over-the-toilet frame. The hire/ purchase of this equipment for use at home after discharge, can be arranged by your Occupational Therapist.

Dressing

It is best to dress sitting down post-surgery, ensuring that your back is well supported when dressing your lower body. When putting on socks, sit on a chair of suitable height, keep back straight, try not to lean forward. Cross one foot over your other leg. Then put the sock onto your foot. Your Occupational Therapist can advise you on correct ways of moving and provide aids to trial to allow you to be independent (such as ezi-reacher, sock gutter, long handled shoehorn, elastic shoelaces etc).

Dressing

General Household Chores

Kitchen Duties

Keep all regularly used items within reach. This may mean re-arranging cupboards. Slide heavy pots, do not lift. Fill saucepans from jug rather than carrying to tap.

Standing

Laundry

Use a trolley to minimise bending Clothes line should be between waist and shoulder height. A peg apron can be useful.

Alternatively, dry clothes in a clothes drier, remembering not to lift heavy loads. When ironing, stand using lunge position (one foot in front of the other) with board at correct height, or with one foot resting on a low stool.

Heavy Domestic Chores

Please refer to section on 'Lifting and Handling'

Avoid transporting heavy or large objects from one place to another after your surgery (eg. leave ironing board in a suitable place rather than taking it in and out of a cupboard, arrange for someone to take out the rubbish).

Carry several lighter loads, rather than one heavy load. Avoid heavy physical tasks, particularly jobs that involve twisting and bending post- surgery e.g. washing the car, vacuuming, changing bed linen, cleaning the bathroom and mowing the lawn. Try to carry a similar weight in each hand.

Gardening

Gardening need not be hard work or stressful on your back. All the previous advice on moving and handling is applicable in the garden. When weeding, use a kneeling stool, and/or long-handled tools. Weed only within arms length.

Driving

You will require medical clearance from your surgeon before returning to driving. When you drive you sit; and sitting places a great deal more stress on your lower back than does standing or lying down. If you experience pain or discomfort when travelling for long periods, STOP, get out of the car and move around.

Getting in and out of the car

1. Ensure the car door is in the fully open position.
   
2. Move the car seat back as far as possible to maximise available leg room.
   
3. Get into the car by sitting on the side of the seat.
   
4. Swing or walk your legs into the car, keeping your knees in line with your shoulders and keep abdominal muscles tight.
   
5. Where possible, use the vehicle uprights, not the car door as support, as car doors are prone to move.
   
6. Reverse the procedure to get out of the car i.e. legs first, then stand.

When seated

Support your lumbar curve. You may find a lumbar cushion or rolled towel placed at your lower back will achieve this.

Things to look out for when buying a new car

• Automatic transmission (reduces the use of foot pedals)
• Power Steering (reduces the amount of effort to steer and turn the car)
• Car seat design  good lumbar support, firm seat, and adequate seat depth/ length.

Consult your Occupational Therapist if you have any problems. They are experienced with vehicle adaptations, driving assessments, equipment and procedures.

Sitting Position In Your Car

Back to Sex

Being careful about your back does not necessarily mean you cannot enjoy sexual activity. Allow 4 - 6 weeks post surgery before resuming sexual intercourse – if in doubt, consult your surgeon.

Avoid positions which involve bending or twisting your back. It is preferable, initially, that you take the less active role. Clear communication is important to let your partner know if you are uncomfortable or experiencing increased pain. Use a firm mattress. For further information, speak to the Occupational Therapist.

Leisure

It is important to continue with your sporting and hobby interests. With good knowledge on the care of your back and some minor alterations in technique and equipment, many activities are still open to you. The most active sporting hobbies which are generally suitable for people with back pain are swimming and walking. Some sporting hobbies involve a lot of bending. It is important to protect your back when picking up a ball or heavy object by adhering to the previously discussed rules for lifting.

Relaxation