Monthly ArchiveOctober 2008
Writer's Block 18 Oct 2008 07:53 pm
Oct. 18, 2008
Here are a couple great questions from this week’s mailbag (edited for brevity)…
I just read your latest blog post on herniated discs … does this mean we should never bend forward?
Also, I do 100 sit-ups a day to build core strength … am I on the right track?
Any recommendations would be appreciated.
A Curious Reader
Those are some very good questions.
First, should we avoid bending forward?
Based on McGill’s findings, (quoted in my last article) slowly and gently bending forward should not pose much of a risk factor. He demonstrated that under moderate pressure (260 N) that even with 85,000 flexion cycles (forward bends) the disc did not herniate.
This would seem to indicate that, if you have healthy discs, normal everyday activities such as bending and stooping should not pose much of a health risk. As McGill puts it…
“It would appear that the disc must be bent to the full end range of motion in order to herniate (Adams and Hutton, 1982).” 
“Disc herniation is associated not only with extreme deviated posture, either fully flexed or bent, but also with repeated loading in the neighborhood of thousands of times, highlighting the role of fatigue as a mechanism of injury (Gordon et al., 1991: King, 1993).” 
There will always be exceptions to every rule, but I am not yet ready to accept the idea that forward bending is intrinsically harmful. I believe that the body was designed to bend in all directions and that there is no reason to fear normal everyday activities.
The real problem seems to be with prolonged sitting or forward bending, rather than the mere act of bending forward.
Now, about your second question concerning sit-ups and lower back rehabilitation, it is my opinion that:
- Sit-ups are not necessary (and may not be a good idea)
- Sit-ups are an advanced stage exercise only
- If you are going to do sit-ups, be sure to do them properly.
What’s Wrong With Sit-ups?
Several highly regarded rehabilitation experts, including Dr. Stuart McGill and Dr. Jolie Bookspan, take a very dim view of sit-ups. Dr. Bookspan is especially adamant on this point.
Personally, I take a more moderate stance on the subject, but you should keep in mind that I’m not an expert. I’m just a journalist and you should adjust your conclusions accordingly.
Which is a round about way of saying that I don’t totally agree or disagree with them. I still occasionally do sit-ups and don’t seem to be having any problems, as a result. On the other hand, if they are correct in their conclusions, you may want to modify your routine.
One thing I will say is I don’t believe that doing sit-ups is necessary for developing lower back health. I am quite certain that it is entirely possible to completely rebuild your back and never do a single sit-up.
Sit-ups are an Advanced Stage Exercise Only
Here is where I totally agree with Bookspan and McGill.
I am quite certain that sit-ups and crunches are not a good idea during the initial stages of rehabilitation especially if you’re dealing with a herniated disc. They place too much compressive loading on the disc and this can only exacerbate the problem.
On the other hand, I don’t believe (or am not yet fully convinced) that slow, gentle partial sit-ups and crunches are harmful once you reach an advanced stage of back rehabilitation.
That is, provided they are performed in the following manner.
How to Properly Do Sit-ups.
What I consider the correct way to do a sit-up is to perform them slowly and gently and not to go to full flexion.
My preferred technique is to perform a slow partial sit-up where you keep constant tension on the abdominal muscles at all times. This allows you to feel the burn sooner and get faster results without having to do a high number of repetitions.
In other words, my technique is to:
- Slowly curl up one spinal segment at a time with the tummy creased.
- Strive to feel the tension and the burn in your tummy muscles.
- Do as many as you can and don’t worry about how many that is. If done correctly you should feel it in your tummy, not your hips.
- Only rise up as far as illustrated below. Like I said, a partial sit-up.
- Don’t release the tension when you lower back down.
This is a very tough way to do sit-ups, but the good news is, you don’t have to do very many.
How Not to Do Sit-ups
Despite my less than stellar illustration above, I don’t recommend locking your fingers behind your head. According to the experts, it causes you to place unnecessary strain on the neck and takes your focus off the abdominals.
After all, you’re not trying to pull yourself up with your arms; you’re trying to work your abs.
Instead, the above illustration is supposed to show the fingers lightly touching the side of the head. (Sorry, I’m not much of an artist.)
Alternately, some people fold their arms across their chest. Others prefer the Pilates style of reaching straight forward toward the knees. I suggest trying them all and choosing what works for you. Just don’t pull on your neck.
Secondly, it is pointless to jerk or fling yourself up like so many people do in order to do more repetitions or to get it all over with quickly.
By doing sit-ups and other abdominal exercises as slowly as possible — mentally curling one vertebra at a time — you reach and strengthen the small muscles that surround the spine.
These small muscles are what connect and support the vertebrae and are just as important to rebuilding your back as are the larger more visible abdominal muscles.
One properly done sit-up is worth 10 done incorrectly. You’ll still get six-pack abs and you’ll get them sooner with less work. So take your time.
To be quite honest with you, I don’t do many sit-ups. I generally do one set of about 30 repetitions and I only do them maybe once a month. Seriously. I figure if I can’t get the job done (a full burn) in 30 repetitions, I must not be doing them right.
Keep in mind that this is only my personal maintenance routine. It’s not a recommendation or a prescription. I’m not training for sports. My only interest is in maintaining overall back and joint health. Furthermore, sit-ups are just not my go-to abdominal exercise. I much prefer more effective exercises such as hanging leg lifts.
I hope this has given you some food for thought. I’m going to go workout, now.
1. McGill, S. Low Back Disorders, Evidence-Based Prevention and Rehabilitation, 2nd Edition. (p. 45) Human Kinetics (2007)
Writer's Block 04 Oct 2008 05:23 pm
Oct 4, 2008
This is the final installment in this series on sciatica and epidural injections. So far we’ve discussed what epidural steroid injections are, what they’re not, how to tell if you’re a candidate, the possible risks and side effects, and finally today we’re going to look at the procedure itself.
Epidural injections are a fairly simple procedure and can be performed by almost any physician, although your family doctor will probably refer you to a specialist. Orthopedic surgeons, neurologists, or anesthesiologists are normally the ones providing this service.
Choosing a Physician
Beyond the normal things you would look for in a physician, you want to be sure to ask if they use something called guided fluoroscopy. Fluoroscopy is a live x-ray procedure that allows the doctor to guide the needle into a precise location. Once the needle is correctly placed in the epidural space, a contrast material can be injected so that the doctor can see if the medication will completely reach the nerves and adjust things if necessary.
Without guided fluoroscopy, the chance for failure is greatly increased. If the needle is simply inserted blindly, the medication may not get injected into the right spot. If the medication does not reach its intended target, the entire procedure will be for naught.
You want your results to be successful, so be sure to ask about this ahead of time.
The Big Day
On the day of the procedure you will be asked to rest and avoid strenuous activities. In addition, they may ask that you refrain from eating or drinking for several hours prior to your appointment. This is mainly for cases where sedation is required.
Also, be sure to ask your doctor about any pain medications you’re currently taking. They may not want you on anything that could cause complications during the procedure.
Allow yourself plenty of time. The actual injections only take about 30 minutes but you should plan on setting aside a full two hours because there is always some waiting prior to getting in and up to about 45 minutes of recovery time after the procedure.
The Preliminary Steps
First, your physician may have the nurse start an IV so that medication can be administered if needed. Usually this would be something to help you relax.
Next, they have you lie face down on the table with a pillow or similar support under your midsection to slightly curve your back. If this position is painful for you, they may have you lie on your side or sit upright.
Once you’re positioned comfortably, your lower back will be cleaned and a local anesthetic will be administered to numb the area.
When you’re ready to go, the doctor will insert the needle and direct it to the correct location using the guided fluoroscopy mentioned above. You may feel some pressure during this part of the procedure, but it is usually not painful.
Next the contrast dye will be injected to make sure that the steroid solution will reach the desired target.
If the needle is in the correct position, the steroid will be injected along with an anesthetic to help numb the area. Again, you may feel some pressure as the epidural is injected, but this is usually not painful.
At this point, they will monitor you for about 45 minutes to make sure there are no complications and then send you home.
What to Expect After the Injections
You will probably need to rest for the remainder of the day. By the following day, you should be able to resume normal activities. In addition, you may be a little sore around the injection site once the numbing medication wears off, but this is usually tolerable for most people.
Some people experience a temporary increase in pain after an epidural injection. This can be caused by irritation from the medications or simply because of the increased pressure in the region due to the shear amount of liquid they inject into your back. This pain usually resolves within few days.
If you do experience any complications following the procedure, be sure to contact your physician for specific instructions concerning what to do.
Wrapping Things Up
I want to repeat what I said at the beginning of this series. I am not advocating for this procedure as strongly as it may seem. I’m not suggesting that you get the injections at all. That decision is entirely between you and your doctor.
What I am trying to do is provide you with accurate information about epidural steroid injections so you can make an informed choice.
This is an extraordinary measure. It is not something that I would undertake lightly. There are always risks and potential side effects anytime you undergo a medical procedure, and these injections are no different.
Epidural steroid injections are not a cure-all. They are merely an option that some people may want to consider. They may be able to provide you with a temporary window of opportunity to proceed with a good physical therapy program.
Don’t make the mistake that some people make of assuming that epidural injections are going to solve all your back problems. That is not their purpose, and you will just wind up disappointed.
I’m going to make this the final post in this series, but that doesn’t mean we’ve covered everything. I already have a supplemental article in the works that I think you will find interesting. So stay tuned.
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