BRITISH BROADCASTING CORPORATION
RADIO SCIENCE UNIT
CHECK UP
Programme No. 4 - Posture
RADIO 4
THURSDAY 20TH MARCH 2008
PRESENTER: BARBARA MYERS
CONTRIBUTOR: PETER SKEW
PRODUCER: DEBORAH COHEN
NOT CHECKED AS BROADCAST
MYERS
Hello. If you go to the doctor with a bad back he may prescribe painkillers but he probably won't arrange an x-ray and it's unlikely that he'll refer you to a specialist. And that's not because your problem is trivial or because he's trying to save the NHS money, it's because evidence now shows that the best way of dealing with a bad back is simply to keep moving. But what does that mean in practice when you can't even get comfortable lying down and the very idea of exercises to keep your back strong and supple seem simply out of the question?
Well if you are struggling with your back and you want to know how to look after it now and in the future you've come to the right place. Here, sitting comfortably I hope in the Check Up studio, poised to take your questions is Dr Peter Skew, he's a doctor with a special interest in musculoskeletal problems and he's a guiding light in the back care campaign.
Our first caller is on the line from Scotland, we've got Neil Stirling waiting to speak to us. Neil, your question please. No he's not there, at least if he has I can't hear him. So let me put the first question - which is to say, we're talking about bad backs, are we talking here about backs that are sort of made bad, we come out born with bad backs possibly a bad shape or is it really about how we abuse our backs during our lives that actually makes them bad, is it anatomical or is it functional?
SKEW
Well we're actually beautifully made. The spine is designed to be flexible and keep our head and our sensory organs up where they can be useful. Some people are genetically determined to get early degeneration and this has been proven by twin studies in St. Thomas's but mostly it's how we use them or abuse them or just ignore them.
MYERS
Okay. Let's see if we can go to another caller, I think we may be having problems. No, I'm being told we've got problems with our line. In which case let's talk a little bit about the sort of people that you see, I know you're an expert in musculoskeletal problems and deal with people who have a variety of different types of back pain but not necessarily from the medical point of view, it's not perhaps osteoporosis or it's not sciatica, it's about how you help people develop their own backs and perhaps strengthen and make supple their backs. So what's the key to all that Peter?
SKEW
Well what you're talking about is dysfunction and this is the cornerstone of the osteopathic theory that the spinal dysfunction causes the problems of pain. If you are abnormally using things - and remember the old adage - song - that the knee bone's connected to the thigh bone, you can't have problems in one part of the system, especially feet, ankles, knees, hips, without affecting everything above. And the last common place to keep your sensory organs functional is the neck, so that's why a lot of people get tension headaches and neck pains when they've got simple things wrong with their lower backs or feet.
MYERS
Okay I think we can go to our calls, as I can't hog the questions any longer, we'll go to Neil, Neil if you're there, in Scotland with your question please for our expert today.
STIRLING
Hi Barbara, can you hear me?
MYERS
I can indeed.
STIRLING
That's great. Hello, good afternoon Dr Skew.
SKEW
Good afternoon.
STIRLING
Good afternoon. I'm a 43 year old male, I'm 5 foot 10 and I've had lower back pain for a few years. When I called on to see my GP - oh this was about a year or so ago - he gave me cheap exercises to do for my lower back but it didn't really help. The pain is uncomfortable if I'm standing for long periods of time or if I'm out shopping with my mum outside a shop, when I get back into the car maybe say after 20 minutes it really is extremely uncomfortable. And as I sit in the driving seat you know I sort of come back down to my normal the pain goes away. And I was wondering if you could maybe perhaps have any theory on that.
SKEW
Well not trying to diagnosis over the phone but patients who have pain that comes on with standing, it's a condition regarded as the cocktail party syndrome, as you can understand, people stand around at cocktail parties. And this is usually associated with sprains of the ilea lumbar ligament, which is a ligament between the top of the pelvis and the fifth lumbar vertebra. And basically what this means is that instead of your muscles supporting your spine you're actually hanging on your spine and the ligaments associated with it and therefore you sprain the ligaments. And the answer to this is to improve the strength and to use your muscles to support the structure. You shouldn't - your spine and your skeleton it's not a coat hangar, it's like a tent post, it has to be held up and if you strengthen the muscles and improve the posture so that the forces are going directly through the correct parts of the joints and the joints are all mobile you take the pressure off the ligaments.
STIRLING
I walk a lot doctor, does that help any?
SKEW
Walking usually just frees things up, but if your posture isn't dynamic enough - isn't strong enough - you will still be working on the ligaments rather than working with the muscles, so you have to have very specific strengthening exercises. And for ilea lumbar ligament sprains you can have injection therapy for that.
MYERS
Is there a very specific strengthening exercise because I know your whole theme Peter today is about strengthening the core muscles which are going to support your back, is there something that we could be doing quite literally as we're sitting and listening to this programme today?
SKEW
Well absolutely, core stability exercises are very simple and the ones I've been recommending to my patients for several years now are - can be done as we're sitting here and I'll do it with you because it makes it easier. You want to sit in a proper sitting position with your spine upright, hands on your thighs, elbows by sides, pull your tummy in, keep breathing as normal, and I'm speaking and I'm pulling my tummy in at the same time, and with your hands on your thighs push your hands down on to your thighs and as you do so you'll hear the resonance of my voice change because my tummy muscles are contracting and as I relax the resonance of my voice changes again, so pull your tummy in, push down with your hands on your thighs and what you're doing is pushing your upper body away from your lower body, so you're stretching your spine and encouraging the core stability muscles to offload the spine. And this should be done for 20 seconds a 100 times a day. You can do it sitting on the toilet - there's not many exercises you can do there. You can do it at the dining table, you can do it watching television, you can do it standing in the queue at Tesco's because you just need to bend your knees slightly, put your hands on your thighs, pull your tummy in and press against your thighs.
MYERS
That's very clear indeed. So let's - if we all do that we really will get the benefit, is that what you're saying, all of us?
SKEW
Absolutely no doubt. I've proven this because I've had back pain since I was 18 throwing the javelin and having a cold water nerve pain down my leg and I've always had backache playing squash or doing other things. In the last four years I've been demonstrating this exercise rigorously, I can go to the tip now with a yard canvas bag, throw it over the side and I don't get any back pain at all.
MYERS
Very good news, thank you very much for that, I hope that's going to help Neil and lots of other people. I've been doing the exercise as we've been talking and I promise I will do it more often. But let's go to another - well we'll go to an e-mail in fact. Kate Hunt has e-mailed us. She's had chronic lower back pain since the birth of her son 22 months ago and Peter is already raising an eyebrow. The baby was born by caesarean section, he was quite big. The pain is quite deep, it's in the central lower back. She's had x-rays, nothing wrong with the spine but she - yes she's very uncomfortable and she also feels as though she's in a bit of a vicious circle somehow - pain meaning that her options to exercise are rather limited. So is that a story you've heard before, that sort of thing?
SKEW
Very much so. Twenty two months ago, four years ago, twenty two years ago, people's back pain often starts just after pregnancy. It's very cruel because you have the baby, you've got this precious lump that's only going to get bigger to carry around but you've got no core stability muscles to help you support your back. So immediately you're put in a position where you've not got the support mechanisms, the extended family for one thing, but also the core stability muscles. You've got to carry, you've got to do the washing, you've got to hang things up, you've got to bend and stoop all the time, lean over the side of the cot. And this all puts tremendous pressure on the back without core stability muscles. The answer to this is exercise those core stability muscles. The bus stop exercises are the ones for the perineum where the baby would normally come out but in this case the baby was delivered by caesarean section, so the operation wound has again caused pain in the tummy muscles, you're disinclined to use them, they get weak, they switch off and they don't switch on again unless you make them.
MYERS
So some of the exercises that we've been talking about and there are more details on our website, these would all be very helpful and Kate's sort of implying that doing exercises could make it worse and I think that's a worry a lot of people have. But we're talking about relatively gentle exercises, we're not talking about going to the gym here are we?
SKEW
Well if you go to the gym the tendency is to do sit ups, you want to get your tummy muscles stronger, unfortunately that's using the spine as a fulcrum, so you are compressing the spine. The exercise we've just demonstrated together and described for the public is an exercise where you're pushing the upper body away from the lower body, so you're offloading the spine, you're strengthening the core stability muscles without putting the spine at risk.
MYERS
Okay thank you. Let's go to Kent, Gail Brand is waiting to speak to us, Gail over to you.
BRAND
Hello there.
MYERS
Hello.
BRAND
I'm currently actually not able to move much because I had a back injury yesterday and I think it was the culmination of pain that's been developing since Friday in my shoulder, in my head, then down my arm and it ended up yesterday morning with a - when I turned to open a cupboard a ripping pain went through the middle of my back. And I've seen my GP and been given medication and advice but it also coincided with a concert I did on Monday night - I'm a musician, I'm a trombone player - and so Monday night, so Tuesday and then Wednesday I'm in pain. And I just wondered is there anything I'm doing that's causing this because it's not the first time I've had back pain, it's the first time it's been that acute though.
MYERS
I'm wondering if the clue there is in trombone playing, whether we're talking about an occupational hazard, what do you think Peter here?
SKEW
Everything you're doing is causing this.
BRAND
Everything?
SKEW
Absolutely. What you've raised is a very interesting point. You said injury - turning is not an injury, injury requires outside energy to be put into the system for you to damage something. Turning is not an injury. It's creating pain by using the dysfunction that you have in your spine to exacerbate muscle spasm, to trap joints, pinch nerves sometimes, it is not an injury as such. And if people get the idea that they're injuring themselves with non injury movements then the problem's worse than they think it is, or they think it's worse than it actually is, do you see? So the fact that you've created the injury thought raises your concerns and awareness. Basically what you have is postural dysfunction and I suspect because of the position you're in and I used to look after the English National Ballet and the orchestra and they would be rehearsing all afternoon and performing all night, hours and hours and hours and that is not uncommon for high class musicians - rehearsing for hours on end and then performing - and then they have to transport their equipment. Many years ago I looked after the Purcell School of Music and a cellist there used to carry her cello around, well the cello was bigger than she was, it wasn't a surprise she had recurrent back pains.
MYERS
Also given that I guess Gail wants to continue playing her trombone how can she do that without actually causing this sort of pain?
SKEW
Well the important thing is to make sure that the spine is completely flexible and the distribution of her pain suggests that it's the upper thoracic region that is actually causing the problems. And this is an area which can be locked up by asymmetrical movements, persistent postures and it cannot be unlocked other than by manipulation therapy - so physiotherapy, manipulation, chiropractic manipulation, osteopathic manipulation.
BRAND
It does often feel as if my - because the weight of the trombone's borne on the left shoulder and every time I have any pain in my back, shoulder, head, neck it's always in my left hand side, even if I haven't played for a day or so.
SKEW
But the point is that the use of the trombone is very unilateral, what you do with one side you don't ever do with the other side, so you've got this postural asymmetry.
MYERS
So are you suggesting that manipulation to ease the spasm, the muscle spasm, is appropriate and is appropriate now when you've got the pain or would you wait until the pain has eased off and then perhaps try and get some further therapy?
SKEW
First things first, get rid of the pain, once you've got rid of the pain find the muscle spasm, massage that away, find the locking of the vertebra or the dysfunction, the levels of vertebra that don't move one on the other, and then mobilise those. Once you've got mobilisation of the vertebra and symmetry of the muscles you'll then have to find an exercise that corrects the asymmetry of the exercise that causes the problem.
MYERS
Okay. We'll go to another call because I think we've got a slightly different problem from Mary, whose pain is in the lower back, so I'm not sure what's bringing your pain on Mary and how we can help you but anyway over to you.
MARY
Good afternoon. Yes I really wanted to share my experience. I've had low back pain for more than 30 years and I've recently found a solution which I wanted to share with other people, I mean some people are probably aware. I've discovered MBT shoes in the last three years and I do wear them everyday and I actually have no routine low back pain, which is the first time in - I'm in my 50s now and it's the first time in many, many years that I don't suffer every day from low back pain.
MYERS
Mary, we're always extremely happy when people phone in with what sounds like a miracle cure. So MBT training shoes, just describe them for us.
MARY
They have soles like a rocking horse and they are soft and absorbing when you walk and it strengthens your core muscles as the doctor has been telling everyone and because they're shoes that you wear you don't have to put the effort into doing the exercise. I have hyper-mobility problems and it's hard to exercise to a level to maintain the strength in the muscles, I've always found.
MYERS
So Peter, what about this then - MBT shoes - the kind of rocking shoes, is there some sort of scientific rational for why they might be helping - clearly Mary said they're helping her but why they might help other people?
SKEW
I lot of the exercises that we use to stabilise core stability muscles are by introducing instability.
MYERS
Which sounds paradoxical.
SKEW
Well you introduce instability and you get the muscles to work on a reflex basis. So they're working when you don't think about it. One of the best core stability exercises is standing on the tube because you have to balance. The instability is created outside of you and to keep you balanced you have to use your core stability muscles.
MYERS
Is that why you sometimes see people sitting on balls, these blow up quite large balls?
SKEW
Exactly, that's another way and obviously Swiss balls are very difficult to carry around. There is another - biconcave inflatable disc, which you can take to the office, throw on the office chair, which is probably less than ideal, and use as dynamic seating - that's the phrase that one wants to look at. And there are lots and lots of companies who promote dynamic seating in a wide variety of ways. What this young lady has given us is MBT shoes which introduce an instability when you're standing, well you can use the biconcave disc to stand on and have rock-a-board type of exercises anywhere you like.
MYERS
I guess we should just caution that we're not talking about the instability you can get from wearing stiletto heels for example, are we or are we?
SKEW
Unfortunately stiletto heels - actually they are unstable on the heel but they force you to walk on your toes and that takes away the normal gait pattern - heel and toe movement - because you're supposed to roll through your foot. The MBT shoes make you roll through the foot and they encourage that rolling through the foot action because of their rock-a-bottom function. My colleague at the sister hospital where I work wears them frequently.
MYERS
Okay, good - good recommendation. Let's go to Sheffield where Nicholas Hall is waiting to speak to us about his - I think also lower back problem. Are you in an acute phase at the moment or is this chronic for you Nicholas?
HALL
It's chronic but it's my upper back, my upper thoracic back and it's mainly on one side and I have pain pretty much all of the time for a number of years and I've tried a number of things and I don't seem to be able to shift it at all apart from with ibuprofen when it gets really bad.
MYERS
And have you had any kind of diagnosis or any label given to the actual problem?
HALL
I have had some x-rays and I do have a slightly - a slight curvature in the back. And I'm very tall also. And another thing that I've had is I've had a spontaneous pneumothorax on the same side where I get a lot of the pain. But I've tried chiropractic and physio, which helps when it gets very sort of stiff, and the sort of ongoing thing that I do is yoga, which I find has helped me a lot with my posture and to prevent it sort of getting really bad but sometimes it does get bad and sometimes I get really painful spasms.
MYERS
Well sorry to hear about all that and I'm sure you'll be of course speaking for a lot of people who are out there in pain at the moment but in particular then is there anything that Nicholas has said about his medical history that perhaps gives you some thought about how he might find some relief?
SKEW
Well Nicholas has raised a lot of interesting queries in terms of his symptoms. He's tall and slim which would - and hyper-mobile - which would call into question whether or not he's got one of the syndromes like Marfan's Syndrome, which is also associated with lens dislocation, spontaneous pneumothorax, long fingers, flexible joints and therefore this should be excluded. And Marfan's characteristically have a span greater than their height. So the measurement from tip to tip of the fingers out wide is greater than their height. And that's the technical side of things. Also thoracic back pain especially, unilateral thoracic back pain, is a bit of a concern and I'm glad that he's been thoroughly investigated to exclude anything else because that would be the first thing I would do because unilateral back pain, especially in the thoracic spine of a young man is a worrying concern and he's had all the right investigations, so that puts us - our minds at rest. But we're trying to reassure people about their back pain but there are still back pains you want to worry about.
MYERS
So sometimes you definitely do have to go and see the doctor but let's, for the sake of argument, say - and I hope that's the case Nicholas - that these conditions don't apply to you and suppose having gone through the various therapies, could they even have made it worse, things like chiropractic and so on, or have they all played their part and still you're left with the difficulty, Peter do they have a role these various techniques?
SKEW
They do but not for everybody. And certainly with somebody with a hyper-mobility syndrome manipulation can be counterproductive. Yes it helps because it relieves the dysfunction that's there at the time but by mobilising the joints you can sometimes make the ligaments a little bit looser and when loose ligaments is the problem in the first place you don't want to do that. So the only answer really is exercise, exercise, exercise, the right ones to stabilise the joints. It's what I said before - the skeleton has to be held up by the muscles, not the body hanging on the skeleton.
MYERS
So we've been practising our own little simple exercise here but I guess there's a whole routine of exercise, where would people go to be shown, perhaps taken through, these kind of exercise, is there something within the NHS or are we going outside and talking about maybe pilates or Alexander technique which certainly do pay attention to core stability and strengthening and making supple?
SKEW
It depends at the state at which people come to the problem. If it's early and they say well look I've got a bit of back pain, I don't want to live like this, they're motivated, they're self-fulfilling, then core stability exercises from pilates, with yoga for people who are a little bit stiff, not for people that are hyper-mobile, for chiropractic, osteopathy - they all have a role. On the strengthening side if you end up in the physiotherapy department they will always give you strengthening exercises because there's only two things you can do to muscles - you can stretch them to get them even or you can strengthen them.
MYERS
I think Amanda wants to come in, she's on the line from Bingley and has got something I think to say about things that have worked for her, so over to you Amanda.
AMANDA
Yes, thank you very much, good afternoon Peter. Very briefly I've had a problem with a ruptured disc in my lower back which was successfully operated on last year but has unfortunately re-ruptured. I've had a series of different kinds of spinal injections for the pain but nothing really seems to have worked and I'm waiting for another operation. My consultant has said that exercise is really important to try and strengthen the core but has advised against swimming, which is something that I really enjoy and actually when I'm in the water I don't feel the pain.
MYERS
Can we get a quick answer on that - swimming - let's just put it to Peter, very quickly - swimming, kind of yes or no?
SKEW
Swimming and hydrotherapy are excellent for back pain. The problem is that most people swim breast stroke and with the extension in the neck and the breast stroke kick it really puts tremendous pressure on the lower back...
MYERS
So like a lot of these things it's doing these exercises but doing them properly and getting some instruction as to how to do it properly. Okay we're going to have to leave it there as ever we're out of time but thank you very much to all our callers and those who e-mailed us and thank you to our expert today - Dr Peter Skew. If you missed any of the answers listen again, you can hear the programme on our website at bbc.co.uk. You can download the programme as a podcast and you can also ring our free and confidential helpline, 0800 044 044.
Next week join me at the same time, same place, only the subject is different, this time we'll be taking your calls about how to get a good night's sleep. In the meantime I hope you have a good Easter break.
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