the back, as this can put a strain on the posterior joints. Progress by repeating with arms stretched sideways.

In this way, the back extensor muscles work, but no stress is put on the joints.

2. Lie trunk over a firm table with a folded towel under hips: hold onto edges of table: lift

both legs to horizontal and hold for a count of 4.

This is a very strong extension exercise.

Leg strengthening exercises-Such exercises are important for safe lifting.

1. Sit on a firm chair; hold arms in front; stand up and sit down 10 times. Next stage: sit on a

low stool and do the same exercise.

2. As 1, but on only one leg; repeat with the other leg.

This is a very strong exercise.

3. Stand on one leg with your eyes closed for a count of 20. Repeat with other leg.

This is an exercise for balance.

Exercises mainly for the thoracic spine

Women seem particularly vulnerable to thoracic (chest level) spine strain, perhaps from lifting babies in and out of cots and prams, lifting shopping out of the boot of the car, and so on. Try to be aware of the potential problems and straighten the middle part of your back before lifting.

The muscles across the back can feel stretched and ache, pull your shoulder blades together to tighten them, don’t use exercises that increase pain.

1. Sit on a chair with knees apart. Bend sideways to reach with one hand down towards the

floor; at the same time raise the other arm sideways and backwards, rotating the spine to look

at the up-stretched arm.

2. Kneel down and sit on heels: bend forwards and rest forehead on floor in front of knees,

arms by your side with palms downwards. Keep sitting on heels with ribs touching thighs; lift head and shoulders without arching the neck. Lift arms and turn them so that the back of the hands are facing each other.

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But if you wake up with a feeling of stiffness which does not disperse until you have been moving around for a while, the cause may simply be your bed.

Mattress-A very soft or sagging mattress makes your vertebral column sag, and can stretch the ligaments that support it. This matters less if you change position frequently in your sleep, but if you tend to lie all night in one position, these ligaments may be strained.

A good bed should support the body evenly, and be easy to move about on. If you’re painfree, your mattress is probably OK.

If you decide to buy a new bed, choose one with firm support; avoid a base which is too soft or springy. Choose a reasonably firm mattress: buy one which has some ‘give’ but still provides support. Try before you buy.

You can make the base firmer by putting a board under the mattress, provided that the mattress itself is not disintegrating with age. The board should be as wide as the bed base and at least as long as the distance from your head to your buttocks. The test is ‘is my pain less with this change’.

Pillows-Arrange the pillows in the way that seems to you most comfortable. A pillow placed between the head and shoulders needs to support the neck rather than the head. There is seldom any need to buy special pillows, except you may prefer a featherdown pillow which ‘embraces’ the head and neck. Two pillows are sometimes better than one but they require positioning for your personal comfort.

Too many pillows, or too thick a pillow, can push the head up, stretching the neck; and while you are asleep, the neck is then apt to bend sideways or forwards and the spine to become flexed. The neck vertebrae should always be kept close to the continued line with the vertebrae of the chest and in the natural curve of the neck.

Lying on your back with the head resting on a ‘butterfly’ pillow supports the head and stops it lolling from side to side. You can make a butterfly pillow by taking a thin or loosely-filled pillow and shaking the filling down each end. You may find it necessary to place another pillow underneath.

For someone who needs lots of pillows at night because of a bad chest, it is best to organise the support so that the whole spine rests on an incline. You may be able to do it with pillows; or it may be possible to incline the whole bed by raising the legs at the head on to blocks. The aim is to keep the whole spine, trunk and head in line with each other.

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The type of exercise prescribed depends on the patient’s condition, on how long the patient has been out of action and on how fit the patient needs to be to return to normal life. What is suitable for one patient is not necessarily right for another.

If any exercise causes pain it may be aggravating the condition, so tell the physiotherapist when you find a movement painful. The exercise may have to be adjusted accordingly.

Some exercises are designed to strengthen and mobilise the spine when it is extended. Others strengthen the abdominal muscles; sideways bending and rotation (twisting) help to mobilise the spine. To do this, the therapist may provide manual or other resistance to particular movements.

Spinal exercises in a hydrotherapy pool in warm water, allow movements with gravity eliminated.

Some physiotherapy departments adopt the ‘back school’ approach in which exercises are carried out in groups. Classes with others help to raise morale and individuals can encourage and support each other. The competition often has a stimulating effect. Physiotherapists try to ensure that exercises match the age and needs of the individual.

If you have been taught to do the exercises and are expected to do them at home, make sure that you do them. Do them regularly and carefully, and for short periods at a time – if you have forgotten to do your morning session, do not do twice as much in the evening to catch up! Doing your exercises to music or while listening to a regular radio program may help to remind and motivate you. If rest is suggested during or after a set of exercises, this is important and should not be skimped.

Isometric exercises-It is possible to contract the muscles very strongly but not move the joints at all; this happens in arm wrestling. This muscle action is called isometric exercise. The method has a particular benefit for back pain. Where inflammation of joints makes moving them painful, a special range of isometric exercises can be used which strengthen the muscles by bracing them without moving joints.

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Getting dressed may be difficult, especially putting on socks, shoes, pantihose and trousers, and it may be wisest to stay in dressing gown and slippers for the first day or so you are up. If you feel that you must get dressed, wear whatever is easiest to put on. A woman can choose a dress rather than trousers, and leave off pantihose. Slip-on shoes are preferable to lace-ups. A long-handled shoe horn can be a help.

If you must put on pantihose or trousers, put them on while lying on your back with your knees bent; but do not raise your hips to pull them right up, which could arch your spine – get off the bed and then do the pulling-up.

There is a gentle exercise that is worth trying when you are feeling less sore. If the pain is in the lower back, while standing put the palms of your hands on your hips, on the bony crests on either side of the pelvis, and holding it steady, sway your shoulders backwards beyond the level of your hips, thus extending the vertebral column. Do this slowly and gently, and stop at once if the pain increases.

If the pain is in the upper part of the back, interlock your fingers behind your head; press your elbows back in line with the shoulder joints, pulling the shoulder-blades together.

Do not drive a car, and take care, when you are a passenger, how you get into your seat. Rotation at the neck or waist may bring the pain on again. Get in slowly, preferably by standing with your back to the seat, then sitting down with your legs outside, and then slowly swivelling round while lifting your legs in, with your hands behind the thigh.

Until you are completely fit again, do your best to avoid lifting and carrying heavy weights. If you really must carry things – essential shopping, for instance, divide the load equally in two, one bag in each hand. Or you could try a back pack, which someone else would have to put on for you. Above all, make sure not to repeat the movement which brought on the attack, if you know which one it was; and in general, avoid twisting and bending movements.

Remember: bend at the knees not at the back.

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Spondylolisthesis-This is a condition in which a vertebra slips forward out of alignment with the part of the spine below it. It commonly arises in the fourth or the fifth lumbar vertebra, so that all the rest of the spine moves forward out of line with the sacrum. The usual cause is a defect or crack of the neural arch (spondylolysis), which causes the facet joints of the articular processes, which normally hold the vertebrae in line, to loosen their hold.

Much less commonly, the slippage may be in a backwards direction; it is then called retrolisthesis.

The causes of the trouble may come from a hereditary weakness of the neural arch: it seems to run in some families and some races, being common among Eskimos. It may, however arise from injury, such as a heavy fall on to one’s behind; or from constant stress, as in the case of athletes and gymnasts; or simply from wear and tear in middle age.

In spondylolisthesis the damage, unlike many vertebral fractures, does not heal spontaneously, perhaps because the lumbar spine has a natural forward curve.

There may be severe pain, if deformation of the neural arch or the displacement of a vertebral body causes pressure on a nerve; if the slippage damages the disc fibres and brings about a prolapse, or if it causes repetitive stress on adjacent ligaments and muscles.

Cumulative damage-However, most damage to the bones of the spine is cumulative. The spine is a symmetrical structure, and can be damaged by stress that is unequally distributed. When the vertebral bodies are continually made to bear uneven stresses by being loaded more heavily on one side than on the other, wear and tear causes irregular shaping of the bone material.

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