Of Interest to Those with Neck or Back Pain

Hormesis: A stress on the body that at low dose has a beneficial effect and at high dose has a toxic effect. Examples of hormesis include moderate exercise, dietary restriction and low doses of certain phytochemicals such as polyphenols (e.g. reservratol)— Stephan Guyenet

Slouched Posture: Efficient or Not? Inspired by Todd Hargrove's post at BetterMovement.org: "Is "Efficient" Movement Unsafe?"
I remember reading that good posture was the most energy efficient way to stand and sit. But why does it seem to take so much more energy to keep the spine straight than to slouch, and especially when fatigue or illness overtakes us.

If energy efficient means using the least amount of energy to perform work then at first glance, slumping with rounded back does seem to take less energy because the back extensors, a large group of back muscles, slack off from straightening the back and let the weight of the upper body hang passively off spinal ligaments and joints. But is the spine well suited to supporting this much dead weight by itself? The short answer is "NO" because the spine has inherent flexibility that allows it to bend when needed for everyday activities. The fact is that by itself the normal spine cannot be both flexible so that we can bend down to tie our shoelaces and inflexible enough to completely support our bodies.

A fused spine can't bend and therefore doesn't need stabilization, but a normal, flexible spine does and that stabilization is provided by the balanced action of two antagonistic groups of muscles—the back extensors, which bend the spine backwards, and the front abdominals that bend the spine forwards. For ideal posture the extensors and flexors act in concert to stiffen the spine as close to vertical as the natural curves allow. This is the spine's most stable and least stressful/damaging upright position and results in even distribution of compressive forces on intervertebral discs. When the back is excessively rounded forward, discs are unevenly stressed, and over time their outer layer or annulus prematurely develops tiny cracks that cause loss of moisture and disc height, which then causes spinal instability, increased pressure on facet joints, bone spur formation and stenosis.

A rounded back also causes an imbalance of body weight. Optimal distribution of body weight is important for our ability to stand upright. Moving around on two legs is precarious to begin with. And if the ten to fourteen pound head juts to the front of the body and the upper back, shoulder and arms also curve forward, it's more difficult. There is already a weight imbalance due to the ribcage/chest area extending out front from the thoracic spine, which causes a constant forward bending pressure on the spine.

To deal with that weight imbalance, the body must realign itself to keep from falling forward. One of three strategies is used.

1. The back, from the low lumbar to mid thoracic spine, flattens as much as possible. But since the upper back and head are still held forward of the torso, and there's no counter-balancing weight, the entire body leans a little forward, not so much that one would fall over (unless trying to do balance exercises), but enough to have difficulty flattening the entire back and head against a wall without extending (bending slightly backwards) the back. See Flat Back Posture

2. The upper torso shifts backwards in a long, rounded curve, which is also counterbalanced by the pelvis shifting forwards. See Sway Back Posture.

3. The hunched upper back is counterbalanced by the abdomen, which pooches out because of an excessive inward lordotic curve of the lower back. The upper back and butt may touch the wall, but there'd be lots of space between wall and lower back. See Kephotic-Lordotic Posture.

All three postures produce their share of sore backs and necks.

Now, getting back to the subject of "Efficient Movement." A better definition for "efficiency" here, would be "The least energy used to achieve the best possible result." The back extensors must be engaged to stabilize the spine, so that body weight and other forces are borne with vertebra stacked vertically, one on top of the other. and the forces are spread evenly on discs and ligaments. When the back is erect, body weight, including the head and upper body, is balanced. Back neck extensors, hamstrings, hip and knee extensors are not over-tight. Of course if adaptively shortened from long term poor posture, these muscles need to be gradually stretched to return them to normal length and tension. (see a Physical Therapist for advice.)

In Todd Hargrove's words: "any local gains in energy efficiency from “floppy joints” are more than offset by a general loss of energy efficiency that comes from poor alignment of the bones and inadequate stabilization of the joints....In other words, valgus knees (knees collapse inward), rounded backs, and overpronated feet (foot rolls inward and arch collapses) are not actually energy efficient at all, because they sacrifice the stabilization and proper bony alignment which is the key to efficient movement and posture."

Yes, it feels easier to slouch especially when one is tired or not feeling well. Add a chronic illness, and it seems like there's little energy left to stand tall with good posture. But it is so worth the effort because the strength and balance of postural muscles is preserved and the chances of postural neck and back pain are greatly reduced.

Rear and Side View Car Mirrors: A panoramic rear view mirror* became a necessity when my neck muscles were so spasmed I could barely turn my head. To this day, I still use it; it feels wrong not to. Why donít all cars come so equipped? They have loads of new technology and safety equipment, front and side airbags, hands-free blue tooth, GPS, T.V. and wired for mobile everything. A simple panoramic rear view mirror seems a no-brainer. (However, when I couldnít turn my head at all, I didnít dare drive even with the panoramic mirror; it was just too dangerous.)
   * Auto parts stores have inexpensive, light-weight panoramic rear view mirrors that fit over the existing rear view mirror.

To help with seeing cars in the blind spot, I discovered that adding a little stick-on convex mirror, in the corner of the driverís side-view mirror was a great help. This also was a necessity when my neck was so sore and stiff. I still use it.

My Fitness Class: I don't know how common this is, but many of the stretching/strengthening exercises in my first fitness class at a local senior center (yes, I am that old.) involved bending forward. Now most people don't bend forward at the hips and keeping the back straight, but bending at the lower back, which rounds the rest of the back in flexion. And there were very few "equalizing" back extension exercises. This was particularly true of the mat exercises, many of them modified sit-ups such as crunches to strengthen the abdominals, or sitting-and-reaching-for-the-toes exercises to stretch the back and legs. (The instructor did say on a couple occasions to bend from the hip, not the back, but practically everyone was curving their upper backs to touch their toes.) There were no back extension exercises, which might help those with hunched over posture. Also the repetitions of the strengthening exercises, with and without weights (light weights), were done quickly in time to music. [But with strengthening exercises the slower, the better; this way both the prime mover and antagonist muscles maintain the contraction longer during all phases of the exercise. For example, if reps of biceps curl are done quickly, the prime mover (the biceps) can take advantage of momentum to lift the weight, and the antagonist (triceps) can just let go and relax allowing weight and gravity to pull the forearm down and elbow joint to open. If very slow motion is used, the biceps cannot use momentum and works harder. And on the way down, the triceps must hold tension (eccentric contraction) while the weight slowly descends, and gets a workout too.] Of course I am probably looking at this all wrong, because we use light weights, which are best for building endurance with lots of reps. After all, the goal of this class is to get people moving and help build some strength in the process, no matter that some of the exercises aren't optimal. What keeps participants coming back is the enjoyment of doing exercise to music and at the same time getting an aerobic workout. I intend to stay with the class especially for the step/dance aerobics, but will skip the exercises that would accentuate the muscle imbalances I'm trying to correct.

Note: I've been in the class almost 3 months and my endurance for the aerobics has greatly improved. I feel stronger, more energetic and look forward to the class. This "working out" thing has taken hold of me.

Habit Formation, Exercise and Posture: As much as possible, the brain converts repeated actions into automatic routines or habits in a process called chunking. Once chunked, behavioral routines require minimal attention or mental energy to perform. All that's needed is a cue (or trigger) that switches the brain to autopilot and starts the routine; and then at the end, a reward tells the brain if this particular routine (may be physical, mental, or emotional) is worth doing again. The cue and the reward become associated so that when the cue is present, a craving to perform the sequence emerges. Cues and rewards can be obvious; e.g. doing the grocery shopping every Saturday morning (cue) and afterwards buying a coffee at Starbuck's (reward). Or not so obvious: washing up before bedtime (cue) triggers toothbrushing, and afterwards the feeling of a clean mouth serves as the reward. Some cues and rewards are so slight that one may hardly be aware of them, but our neural systems certainly are.

Trying to change a habit sequence once it's triggered is difficult because the conscious brain is not actively involved. One approach in particular seems to help; a study on exercise habits showed that when participants were educated about habit formation and then asked to identify cues and rewards that might increase participation in exercise routines, they exercised twice as much as those who only received lessons on the importance of exercise. Simple cues seemed to be most effective. For example, I drop my pedometer (a Fitbit) in my pocket after dressing in the morning (the cue) and take a walk. Checking how many steps are recorded, gives me a little rush of satisfaction (the reward). (A second walk is cued by my dogs, who won't leave me alone until we head out the door in the afternoon.)

For an interesting article on habits see the New York Times Article, How Companies Learn Your Secrets (they want to know when a life changing event, such as impending marriage or childbirth will occur, in order to get a headstart sending out advertising. Otherwise one's spending habits aren't very open to change and advertising has minimal effect. This article is based on the book by Charles Duhigg, "The Power of Habit: Why We Do What We Do in Life and Business"

So how can cues and rewards be applied to improving posture? My experience has been that the feeling of slumped posture can become a cue, and when I become aware of it, I tighten and straighten my mid-back, which lifts my chest and gives me a feeling of release from chest constriction (a reward) and I take a deep breath. Then I do a rep of the Fix the Shoulder Blades Exercise, during which I often remember how much better my profile looks (even when I'm not anywhere near a mirror) and how good my neck feels now versus how miserable it used to be (more rewards). Finding and appreciating those rewards required that I become more aware of how my body looks (especially from different points of view), and also more sensitive to how my body feels, not just pain, but muscle tension, joint position, limitations imposed by poor posture, awareness of shoulder blade anchoring, spine position, posture during movement etc., or everything that comes under the classification of kinesthetic senses. Sometimes I wonder why I didn't always have those sensitivities. Perhaps it was my sedentary life. And perhaps also because poor posture develops so slowly there's never enough difference to notice; and meanwhile the body memory of good posture is slowly lost. As well there's often little feedback from other sources of information, such as visual (generally only face forward view in a mirror is available and that doesn't help in seeing the entire body's alignment), or comments from family and friends (who often don't want to say anything upsetting, even my mother had stopped criticizing), or advice from medical professionals, fitness professionals and physical education teachers (of all the many I had contact with, none ever said anything about my posture). And perhaps also, poor posture itself, and any pain from poor posture, deadens sensitivity to body state. Is it any wonder that a person's posture seems to be a relatively unchanging part of his or her physical appearance, except to slowly get worse with age? In order for a person to improve posture, an epiphany may be needed. And once some improvement has been experienced, the body becomes more sensitive to what a healthy postural state feels like, and strives to maintain that state.

However, there is a matter of backsliding into poor posture, and I do find myself slouching, but only when working long hours at the computer, not when standing, walking or other more physical activities. The good thing is though, that I'm more aware of slumped posture, and I put more effort into correcting it. So why is slumping more likely at the computer? Perhaps because computer work takes a great deal of mental energy, and the mind and body tires quickly. And being tired means less energy for the back extensors, which are the critical muscles keeping our backs erect against gravity. Our body structure doesn't help either. The spine tends to bend forward because the bulk of body weight, is in front of the spine. The thoracic spine, in particular, supports the ribcage and attached muscles and organs, which are a major part of the body's mass. No wonder the thoracic spine, which naturally has a rounded, kephotic curve, tends to curve even more forward under that weight if the back extensors aren't kept strong.

Ultimately, maintaining good posture is a continuous challenge, but it is a challenge that can be won, if one becomes aware that it feels so much better (the reward) than slumped posture. The reward is even greater if one has suffered years of pain from it.

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My son, a personal trainer, told me that one of his clients was complaining of neck pain.  He asked her how often she used her new Kindle Fire. It was then she realized that excessive tablet use was the source of her pain.

Neck Pain From Using Cell Phones, Tablets and Laptops: When using a cell phone for text messaging, anchor your upper arms close to your ribs and bend your elbows to raise the phone closer to your face. Then lower your eyes to see the screen, instead of bringing your face closer to the phone. Iif you still must tilt your head, avoid bending the neck forward and down, instead use the top-most “hinge” joint of the neck. But do try to have your arms and eyes do most of the work.

A handheld tablet with keyboard seems like it would be very awkward to type with (needs thumb-typing or one-handed typing). So a tablet is probably placed on a surface for that. My son says the Apple Ipad has dictation capability; maybe typing is not so necessary. Then there's the stylus, a one handed implement for note-taking. [update: one needs to speak very clearly for Ipad dictation to be accurate (good speech therapy for those who need it!). My son bought a case that tilts the Ipad up so he doesn't need to tilt his head down as much. He also says a case is available that comes with a separate keyboard and also elevates the Ipad. Essentially the Ipad becomes a desktop.]

Typing on a laptop rather than a tablet should be easier on the neck, as long as it is on a surface like a table top, which it seems most people do. But still the monitor cannot often be raised to comfortable eye level so see people bending their necks down all the time. As with cell phones, it is better to roll the eyes down. Better still would be if the laptop screen could be separated and hung at eye level. (Do any laptops come with separatable screens?). For now I am sticking to my desktop computer. At least the monitor can be adjusted to a comfortable height, which for me is just below eye level, so I can see it in the reading part of my eyeglass lenses without tilting my head up. (First I adjust my chair height so my feet rest firmly on the ground and my lower legs are perpendicular to the ground. If the monitor needs to be higher, I use a large book or two to raise the monitor further.)

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Do Glucosamine and Chondroitin help arthritis? Well designed studies say no (see "Glucosamine and Chondroitin for Arthritis: Benefit is Unlikely" by Stephen Barrett, M.D. at Quackwatch. In brief: the largest and best study, the Gait or Glucosamine/Chondroitin Arthritis Intervention Trial, showed virtually no pain relief and an extension of the study showed no significant structural benefit, defined as slowing of the narrowing of the joint space in the knee). Another study specifically studied 250 adults with chronic low-back pain and degenerative arthritis for a year. Half received glucosamine and half placebo with no difference between the two. A more recent study involving 662 GAIT patients looked at glucosamine and chrondroitin sulfate, either separately or combined, and celecoxib (Celebrex) as well as a placebo. No statistically significant differences were found among the groups.   
I myself took Glucosamine and Chondroitin for several months without positive effect, but then Celebrex at that time didn't help either. There are people I know who claim they have been helped, especially by formulations with MSM, but it's no miracle cure. So far there don't seem to be any serious side effects of these supplements, but since supplements in general are not regulated, I'd be careful and also ask a doctor for advice. For a possible mechanism of action for glucosamine see "Food Intolerances: The Controversy Over Gluten Grains and Nightshade Plants: Do They worsen Arthritic and/or Intestinal Inflammation?

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Yoga: As a teenager I dabbled in it, but either injured myself as when I tried a yoga headstand and strained my neck, or began wondering what all that extreme twisting and bending was doing to my joints and ligaments. I watched my dad, a student and teacher of Hatha yoga, who did the positions much better than I could. He also had a lot more determination than I, maybe too much. He would remain in a headstand propped against a wall for quite some time—his face turning bright red. Later I wondered if that had something to do with the Alzheimer's that overtook him in his late 60s. (Or was it head trauma from boxing as a heavyweight on his college team? No one else in his family ever had Alzheimer's.) Anyway, he finally did stop doing the extreme lotus because he figured it caused the painful phlebitis (a blood clot in a deep vein of a lower leg) that swelled his lower leg. The lesson here being: don't do yoga to extremes.
But mostly I've heard good things about Yoga from friends. However, a recent article in the New York Times, How Yoga Can Wreck Your Body, discusses the small but growing numbers of serious injuries to the lower back, shoulder, knee and neck. Glenn Black, a well known New York instructor states that injuries occur because students have underlying weaknesses that need to be addressed first. Also mentioned is Yoga Instructor, Carol Krucoff, who tore a hamstring muscle while being filmed doing Kitchen Yoga for a national TV show. See Insight from injury: If the practice of hatha yoga was meant to heal, why are so many yogis getting hurt? Instructor Glenn Black in another interview, Yogi Glenn Black Responds to New York Times Article on Yoga, lists pinched nerves in the neck, low back tightness, injuries to hips, knees and shoulder problems and also which yoga poses to avoid. And most disturbing of all:

EF: You now have a spinal fusion and screws in your lower lumbar spine to stabilize herniated discs and spondylolisthesis. How did your own yoga injuries come about?

Glen Black: Extreme backbends, and twisting coming up from my hands on my ankles. I overstretched my ligaments and destabilized my spine.

But any sport or activity done to extremes can cause injury. See: Practicing Safe Yoga — 5 Tips to Avoid Injuries by Eva Norlyk Smith, Ph.D.

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Two articles of interest for those considering back surgery:
A New England Journal of Medicine article–Surgery versus Prolonged Conservative Treatment for Sciatica, Conclusions: "The 1-year outcomes were similar for patients assigned to early surgery and those assigned to conservative treatment with eventual surgery if needed, but the rates of pain relief and of perceived recovery were faster for those assigned to early surgery."
The Journal of Bone and Joint Surgery–Surgical Compared with Nonoperative Treatment for Lumbar Degenerative Spondylolisthesis, Conclusions: "Compared with patients who are treated nonoperatively, patients in whom degenerative spondylolisthesis and associated spinal stenosis are treated surgically maintain substantially greater pain relief and improvement in function for four years."

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Pillows: When my neck pain was bad, I went through—I can't remember how many pillows...firm, soft, overstuffed, feathers, brand names, hotel, orthopedic etc.—trying to find one that didn't leave my neck worse in the morning. Finally I took a medium polyester filled pillow, removed some filling from the center to cradle my head, then used the extra filling to form a "hump" at the lower edge to support my neck, and that was about all that "worked," but even that wasn't perfect because the fluff kept compacting. The fancy shaped orthopedic pillows didn't help. The neck support area always seemed too thick and the new fangled "visco-elastic" material never shaped to my neck (which had lost it's normal lordotic curve years ago). So I always ended up whittling away at the foam, reshaping it again and again until I had to throw the pillow out. (Some in my neck/back pain group put their memory foam pillows through the dryer several times to soften them. I think I tried it once but it didn't help.) The one with the little styrofoam beads didn't help either. I opened it to remove some of them; they got everywhere and stuck to everything, and still my neck didn't like it. And then there was the water pillow that I ordered online. No matter how much or little I filled that thing, it still wasn't comfortable. And besides it was heavy with all that water sloshing around and lifting it was tough on my neck.

From all this trying of pillows, it became clear to me, there was no "magic" pillow when one's neck is inflamed and painful. Some can make it worse, especially the high, over stuffed ones that force your neck to curve into flexion/kephosis ("C" curve). But most won't help reduce pain that's already there because of long term poor posture.

Well my neck pain is gone thanks to my new posturally correct self. Currently, I have a nondescript, unmodified, no-name pillow that works fine. I have been thinking of getting a slightly firmer one because I always sleep on my side now. A far cry from when I slept rigidly on my back, towel rolls under the ends of my pillow to prevent my head from rolling to either side.

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Mattresses: When my back was painful and spasmed because I had to sleep motionless on my back all night long (because of my neck), my new Beautyrest mattress was just as hard on my back as the old Sealy Posturepedic. I could feel every little dip of the pattern stitched into the pillowtop...darn uncomfortable. I tried a thick visco-elastic foam topper and after one night—my back spasmed like crazy. The only help would be to sleep on my side, but that had to wait until I'd fixed my neck pain.

The neck/pain support group I belong to has discussed mattresses. The Select Comfort Sleep Number bed seemed to be the mattress of choice. Having separate controls to adjust firmness on either side of the bed for couples was mentioned as a great help. But one member said the massage feature was not helpful and noisy besides. He found the local reps to be very helpful. But of course the sleep number bed is more expensive than most. The Tempurpedic mattress has been mentioned. One woman's comment was that it felt great in the store but once home, did not give support—it seemed to sag—and by the second night she was "crying in pain." But she wasn't helped by an old Select Comfort a friend lent her, either. (This woman was concerned about customer complaints about the pump on the Select Comfort breaking after the 2 year warranty period expired.) Another woman said her Tempurpedic made all the difference in giving her pain relief. And another was sore the next day after trying it in store.

There seems to be back pain patients on both sides—Tempurpedic vs. Sleep number. So which is the best mattress for back pain? Some advice included giving the mattress a try for an hour or two in the store, and then not to consider buying it until after you know how your back feels the next day. As with pillows, a lot depends on the state of one's back. But how do you improve the state of one's back if sleeping doesn't rest it? What will help? Changing sleeping position, improving posture during the day, muscle relaxants, sleeping aids, having surgery if needed? It's a major puzzle and a "pain" to go through trying to figure out.

Of note: one support group member highly recommends an adjustable "hospital" type bed. Check out if either Tempurpedic or Sleep number comes with adjustable head and foot controls.

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