Overcome Neck & Back Pain

by Kit Laughlin

Overview

If you suffer from back pain, as 85 percent of Americans do, you may think there is no way to bring about a complete end to your pain. Books, videos, and even doctors offer ways to manage the pain, but not to stop it. Finally there is a solution. Overcome Neck & Back Pain, the international bestseller, provides a means to end your back pain permanently through an easy-to-follow four-part program of structural analysis and correction, stretching, strengthening, and relaxing.
Kit Laughlin spent years suffering from back pain, and, in search of relief, even traveled to Japan, where he found the solution. Using the principles of hatha yoga, he developed a combination of Eastern and Western medicine that provides a way to stop back pain and even protect oneself from future injury.
Through clear, instructive photos and easy-to-follow instructions Overcome Neck & Back Pain shows the beginner how to use stretching, strengthening, and relaxation to end the pain. Overcome Neck & Back Pain also provides instruction in more advanced techniques, with an explanation of the principles behind the movements. The comprehensive text offers solutions for athletes and nonathletes, old and young alike.
If you've given up hope of curing your back pain, Overcome Neck & Back Pain provides the sensible solution you need.

Product Details

ISBN-13:	9780684852522
Publisher:	Touchstone
Publication date:	12/29/1998
Pages:	208
Product dimensions:	8.25(w) x 11.00(h) x 0.50(d)

About the Author

Kit Laughlin studied oriental medicine during a five-year stay in Japan and, on his return to Australia, was the Japanese ambassador's personal shiatsu practitioner. In 1988 he was asked to treat the prime minister of Japan during his visit to Australia, the first time a Westerner had been asked to provide such a service.
Laughlin was awarded a Master of Letters degree in 1992 from the Science Faculty of the Australian National University, and currently is doing research for a Ph.D. dissertation in which back pain is the key case study.
Laughlin originated the Posture & Flexibility and Strength & Flexibility courses that have been run by the Australian National University Sports Union for the last eleven years. Assisted by fourteen teachers whom he trained, Laughlin has taught these courses to thousands of students of all ages and levels of fitness, with proven results. He is the presenter of the acclaimed Overcome Neck & Back Pain seminars and the author of a forthcoming book, Introduction to Posture & Flexibility.

Read an Excerpt

PREFACE

WHY THE INTEREST IN NECK AND BACK PAIN?

It seems that everyone has suffered neck or back pain at some stage. Neck or back pain affects between 60% and 85% of people. Probably you are one of these people. In one study, researchers reported that 21% of patients experienced back pain in the 14 days preceding the study. Another study reported that at least 5% of all patient visits to the doctor are due to back pain.

Tremendous costs are involved. Neck and back pain account for half the worker's compensation payments in the United States and Australia, they are the single greatest cause of lost work time in both countries, and low back pain alone costs over $85 billion annually in the United States, about one-third of this amount being the direct costs of medical care. The 10% or so of patients who suffer chronic back pain account for 75% of Australia's rehabilitation and compensation payments. The social cost cannot be calculated — back pain is the most frequent cause of inactivity among people under 45 years of age. In the U.S., Great Britain and Australia, the number of people disabled by these problems has increased exponentially since the 1970s, during a period of only modest population increase (Schwarzer, 1996; Rainville et al., 1996).

However, patients are not the only ones to suffer. Back pain has been described as "a wilderness across whose inhospitable terrain orthopedic surgeons, neurosurgeons, physiotherapists and, above all, general practitioners are doomed to travel" (Littler, 1983). Most doctors believe "there is little doubt that most cases are due to derangement of the intervertebral joint in association with 'degeneration'of the disc and arthrosis of the facet joints" (Ganora, 1984), or, as it was put more simply, "more than 95% of patients with low back pain suffer from mechanical back pain" (Schwarzer, 1996, p. 108). And yet an article in the New York Times about a study published in the New England Journal of Medicine raises serious doubts about these claims: nearly two-thirds of a group studied had "spinal abnormalities, including bulging or protruding discs, herniated discs, and degenerated discs" — but none of the subjects in the study had back pain, or ever had suffered from this problem (Kolata, 1994).

What is this book about?

I have found that most neck and back pain is experienced in the muscles associated with the spine. The pain is caused by excessive tension held in these muscles and is the result of a variety of causes, from structural imbalances to various aspects of lifestyle. These causes can be treated. Except for a very small percentage of neck and back pain which can be dealt with successfully by surgery or drug therapy, I advocate a conservative, exercise-based approach, the subject of this book.

What can I do?

My approach to overcoming neck and back pain has two parts. The first step is to help you identify which muscles are involved in your particular problem and to teach you the most efficient ways to relieve this excess tension, using extremely efficient stretching exercises, initially to be done only twice per week. This phase of treatment the rehabilitation phase) is enhanced by teaching you how to use directed relaxation to assist the body to sleep and to enhance its healing tendencies.

The second step (the prevention phase) conditions all of the relevant parts of the body by using more advanced stretching exercises and later, by adding specific strengthening exercises, to provide a measure of protection for the future. In these two chapters, I shall present an approach to neck and back pain that is effective in practical terms and a later chapter considers the problem in theoretical terms, and will help you to make sense of the conflicting research on the problem.

Who should use this book?

This book is written for anyone who suffers recurring neck or back pain, or who wishes to avoid these problems. Recovery isn't quick or simple, but there aren't many other options either. Unless your back or neck problem is of the kind that can be treated effectively by surgery or drug therapy (probably less than 10% of the cases presented to general practitioners), you may have found that the range of options seems limited to avoidance of the activity thought to be the cause or treatment of the symptoms. If treatment is successful, your back will be returned to normal; that is, to its "preinjury" level of function — consequently, there is no guarantee that the problem will not return. My aim is to present a unified and comprehensive self-help approach. For those fortunate enough not to have such problems, the approach will increase the suppleness and strength of your neck and back to reduce the likelihood of injury to these areas.

How this book is set out

The introduction sounds a more personal note than following chapters. It begins with a brief history of events which led me to my current approach, including a rather lengthy stay in Japan where I studied Shiatsu and a number of traditional exercise systems. I consider the various exercise systems from which I derived my own, the courses called Posture & Flexibility, and Strength & Flexibility, currently taught at the Australian National University. My clinic in Canberra (the Shoshin Center) is mentioned, and I present some relevant neck and back pain case studies. The first three chapters include the self-diagnosis method, and the stretching and strengthening exercises — these are the nuts and bolts of my approach.

Chapter one takes you through the self-diagnosis step-by-step. There is a flow-chart of the diagnosis method at the end of the chapter, and a page to photocopy. On this you fill out the results of the leg length tests and the functional flexibility tests. Fill it in as you go through the chapter. There is also an illustration of where pain may be experienced in the neck and back, and exercises likely to be useful are listed alongside.

Chapter two contains the basic pain-relieving and rehabilitation exercises; the first section describes exercises for the back, and the second describes exercises for the neck. These are the most important exercises in the book, and for most people are the only ones they need to do on a regular basis.

Chapter three details the preventive stretching exercises. These are designed to improve and balance your existing flexibility, and allow you to focus more closely on your problem areas with stronger techniques. The second part of chapter three outlines my approach to strengthening exercise, and details a set of graded strength exercises, from a minimal set suitable for doing at home through to more elaborate exercises for which some equipment is needed.

However, do not go straight to the exercises without reading the cautions section below. Inappropriate exercise may worsen your condition, and the nature of the problem is the best guide to selecting the exercises which are right for you.

You will get more out of the exercises if you have a reasonable working knowledge of the anatomy of the areas of interest. For this reason, useful functional anatomical information will be found together with the exercises. Organizing the book this way means that you do not need to go backwards and forwards between the exercises and the anatomical details upon which the exercises so crucially depend. As mentioned, much experience has shown that the actual locus of neck or back pain tends to be the muscles associated with the spine. As each muscle has a clearly definable function, this knowledge will help you locate the particular group concerned, and guide you to the best exercise. The book has been bound so it can be left open on the floor beside you, to enable you to check your form as you practice, and the practical sections include Notes (presented in a larger typeface than the text) that contain the most important details about how to do each exercise. These are arranged alongside the photographs for easy reference.

Chapter four discusses the various causes of neck and back pain, from a number of medical perspectives beginning with that of western medicine. One of the reasons for so doing is that western medicine has the most detailed understanding of anatomy, and this knowledge is fundamental to my approach. Another reason is that we are familiar with the western medical perspective — it is the medicine of our culture. This chapter includes a brief consideration of chiropractic and osteopathy because neck and back pain is the main concern of these practitioners. Oriental medicine and some of the bodywork schools are also considered. Acute and chronic pain are treated separately, and mention is made of additional contributing factors. The chapter sounds a note on the limitations of the very idea of cause with respect to common illnesses, and offers a rationale for my functional approach. The experiences of the workshops we have been running for individuals and practitioners are presented, and consideration is given to choice of beds and pillows.

Chapter five provides a justification for including relaxation techniques as part of the larger approach to overcoming neck and back pain. It discusses practical stress management briefly, outlines the current understanding of stress and its effects on the body, and ends with an easy-to-learn method for relaxation. Useful guided visualization techniques for speeding up the heating process are included in the relaxation script.

Cautions

Before you begin, some notes of caution must be sounded. If you are undergoing some form of treatment at the moment, you must discuss the exercises presented in the book with your practitioner before beginning. It is a matter both of courtesy and safety — some of the exercises may be inappropriate for your condition. Further, embarking on a course of exercises that have not been examined or approved by your practitioner may void any compensation to which you may be entitled. I have written this book in good faith, but I cannot personally supervise your performance of the movements, and therefore cannot accept any responsibility for errors you make. Neither can I know the particular details of a condition you may have — this is your responsibility. These aspects necessitate the greatest caution on your part — the fact that thousands of people have benefited from this system is no guarantee that you will. Consequently you must approach the exercises with caution, and you must monitor the effects closely.

Next,do not refer only to the photographs. You must read the sometimes lengthy descriptions that accompany them. Information vital to safety is contained in the text, along with descriptions of how to press or pull certain parts in certain ways. It is not possible to understand the exercises only by looking at the photographs.

The next caution concerns the order in which the exercises are presented. In most cases the easiest and safest versions of any movement are shown first; these versions are marked easiest in the text. More difficult versions are labeled intermediate; the most difficult are labeled advanced. This is the order in which you should attempt them. Even if you know that you can do a more difficult version, begin with the easiest one. You can always learn something about the way your body works from doing an easier rather than a more difficult version of an exercise, simply because you can concentrate more on your responses to a movement rather than its complexities. Additionally, the easier versions are a useful warm-up for the later ones.

Lastly, I wish to discuss some practical cautions. Exercise in the evenings rather than the mornings as the body is more supple then. You must not exercise within an hour and a half of eating. It is best to exercise in the hour before you eat the evening meal. Always go to the toilet before beginning. Wear clothing that both keeps you warm, and permits free movement. Some of the exercises require a strap, strong towel, or some other method of holding a part of the body, so have something handy. For the first few weeks or months, I suggest that you stretch only twice a week, which may be increased to three times as you improve. The text includes specific instructions on the few exercises I recommend be done daily to relieve the body of the effects of the day's stress. More of this later.

The following caution may be self-evident, but permit me to labor a vital point. You must imitate the form of the exercises demonstrated, not my performance of them. The purpose of the precise descriptions and photographs is so that you can place yourself in the positions I have found to produce the best results. You then proceed with the stages of the movements only until you feel the stretch I describe, and stop at that point. In the demonstration of the movement, I may have taken the particular limb further in the range of movement than you can, but this is immaterial. (You may well be able to stretch further than I in some exercises, too.) The sole purpose of an exercise is to feel a stretch in the right place. Please keep this in mind — most teaching of stretching exercise fails on this crucial point.

The most general, and important, caution I have saved until last. It is that you must listen to what your body tells you while you are doing the movements — no one else can do this for you, not even the best teacher. Very early in your practice you must learn the essential difference between the right kind of stretch sensation and going too far. For this reason, I urge you to do too little rather than too much in the beginning — realizing the difference too late will be painful, and possibly dangerous. Remember the old adage: "Rome was not built in a day."

The Introduction provides you with the background to the approach advocated in the book. If you prefer, you may go straight to chapter one, the self-diagnosis method, and return to the Introduction at a later time.

INTRODUCTION

BACKGROUND TO THE APPROACH

In this introduction, I should like to give you some personal details, which I hope will both be interesting and give you some insight into what led me to develop the methods presented in the rest of the book.

During the early 1980s, I was a television director and a struggling athlete. I trained for the 800- and 1500-meter races, the so-called middle distance events. Directing the Australian Broadcasting Commission's nightly current affairs program Nationwide was stressful enough on its own; together with all the running training — we ran 100 miles (160 km) a week in the winter months — I now think that I was asking too much of myself. I used to hold a tremendous amount of tension in the middle back muscles. Despite physiotherapy and chiropractic treatments, the problem never really improved beyond temporary relief.

Some sort of insight occurred one day when I bent down to touch my toes after an interval training session at Sydney University. At full stretch my fingers came a few inches below my knees, and that was with my back bent like a bow. Someone took a photograph of me doing this, and it ended up on the wall at the H. K. Ward gym (where many of the local track and field athletes did their weight training), suitably inscribed "Rubber Man."

The next insight occurred when I was using the seated heel raise machine (from the seated position a padded bar over the knees is lifted by the feet to strengthen soleus, one of the two calf muscles). I placed my feet evenly on the footrest and positioned my heels level with each other. One knee contacted the support bar. The other was a full centimeter or so lower. Naturally, my first thought was that the machine had been bent by one of the serious bodybuilders using too much weight. I looked at it carefully, got a tape measure from the attendant at the front desk, and after careful checking decided that it was straight. Only then did the possibility that I might not be straight occur to me. Careful measurement revealed that my right leg from knee to heel was noticeably shorter than my left. I mention this only to highlight the point that we resist the notion that there might be something less than ideal in our own physical makeup, but consideration of all possibly relevant information is essential if we wish to overcome our problems.

Once I had accepted the difference (in fact my right leg is shorter by about three quarters of an inch or two centimeters, evenly divided between the upper and lower leg), I began to think about the effects this structural asymmetry might have caused. I had trained for both Olympic and power lifting for years before losing quite a deal of weight to become a middle distance runner. I realized that years of weight training adapted my body to two major stresses — the stresses of the training itself, and the asymmetric distribution of those forces as resolved in my particular body, so not only had I become extremely tight in the process but had also developed an individual pattern of flexibility. I began "limber" classes at a Sydney dance studio, and these patterns became only too clear. I also quickly realized that the approach adopted in these classes was not efficient for teaching adults how to become flexible. The young students were very supple and had become flexible while they were still children. What looked like stretching classes were really preparation, or an extended warmup for their ballet classes later in the day. My experience there made me think about the differences between adults' and children's bodies, and how one might improve on the standard approaches to the problem of how to teach adults to become flexible.

At this time, I experimented with lifts of various thicknesses in my right shoe. The difference it made to running was immediately apparent. The shooting pains in between the shoulder blades experienced in the finishing stretches of my races all but disappeared, and on using the insert the first time, I immediately felt more balanced walking and running.

During the late 1970s I attended yoga classes at various places around Sydney. I found the classes relatively inflexible in their teaching approach: students lined up in neat rows and little dialogue. The strict atmosphere often discouraged questions at the very time one needed assistance. I was disturbed by the tendency for some teachers to accept the pronouncements of their own teachers uncritically. Guru worship was commonplace, and many teachers had adopted the mannerisms and aphorisms of their own gurus. What I subsequently learned to be the correct form of various poses was being distorted by many students in their attempt to imitate the teacher through simple inflexibility. Questions like, "why do we do it this way?" were left unanswered, or deflected with replies like "tradition," or "that's the way the posture is taught by my teacher," and so on. I met few teachers who had more than a passing acquaintance with anatomy — the one aspect of western medicine normally unquestioned by the alternative healing arts. Of course, these were my particular experiences at the time; much has changed since these early days, and anatomical knowledge is now emphasized in contemporary yoga teaching.

During this period I also resumed martial arts training, and so did the kind of stretching usually employed in these arts during the warmup — vigorous dynamic movements, assisted by a partner or an instructor, and all over in 15 minutes before the real training began. No attention was paid to form in the exercises, and I injured myself a number of times using this approach. On one occasion, I pulled a groin muscle (one of the adductors) that took nine or ten months to heal and which was subsequently injured at another training session.

I had my thirtieth birthday in Japan. I had had enough of television, and decided to go to the source for martial arts. I was dismayed to find the same approach to stretching used there too. I found disbelief on the part of teachers who could not accept that someone who had trained for ten years or so was not perfectly flexible. They had no effective suggestions on how to become more flexible. They had all done the usual stretching as children (usual in Japan, anyway), started their martial arts training at an early age and consequently did not need to know how to make an adult flexible. The severe training I went through (I was a live-in student, called an uchi deshi) made my back muscles even tighter. After nearly a year and a half of this life, I found myself unable to recover from an illness that alternated between a cold and influenza for six months. A friend had been studying a form of oriental medicine for a year or so (shiatsu) and, sick of being kept awake at night when I visited, he suggested that I go to see his teacher.

It was a revelation. Never have I let anyone hurt me so much. I was holding a tremendous amount of tension in the muscles of my body, and all the places he worked on, including my back, were incredibly tender to touch. The sensei told me that although my body was strong it was holding excessive tension everywhere, which he felt was the result of the stress of the work I used to do plus the effects of the rigorous current training. He would poke my body and say in English, "Too hard, too hard." I confess I was skeptical of a treatment that consisted merely of maintaining a leaning pressure on various places using the elbows and thumbs mainly, together with a few simple stretches and manipulations of the bones of the body. However, I started to feel better that same day, and by the time of the next treatment (a week later) the cold had gone. It was at the conclusion of the second treatment that I was introduced to a woman who would change my way of thinking about flexibility. Ms. K— was a diminutive Japanese woman around 35 years old. She was the translator for the shiatsu classes presented for foreigners at the center. Sensei mentioned that I was interested in becoming more flexible. Ms. K—'s way of getting to the floor for this conversation involved sliding through the side splits into front splits, then lifting herself into seiza, the normal Japanese way of sitting on one's feet. It certainly got my attention.

Ms. K— and I were to do considerable work together during the ensuing few years on flexibility and shiatsu, as I became a student. She was the sole surviving shihan (senior teacher) of an exercise method called Jikyo Jutsu. Roughly translated, this means "self-help method." Like Tai Chi, it is based on meridian theory, the practice of which is designed to "harmonize energy flow" around the body and promote internal health, in much the same way as shiatsu. This improvement in internal health is said to be responsible for the increase in flexibility that follows. In other words, the acquisition of flexibility was deemed to be a side effect of health. Quite different to our western approach, I thought. The exercises themselves were an interesting mixture of dynamic stretching movements and pressure point therapy. In time I was awarded a shodan (a "first degree" black belt). "Sho" is the character for "beginning," and unlike other parts of the world where a black belt is often regarded as a pinnacle of achievement, in Japan it signifies a starting point.

Part of the learning process of shiatsu involves receiving treatment from one's teacher. I received treatment for a year or more on a fortnightly basis, did the Jikyo Jutsu, and taught and attended yoga classes in Tokyo. By the time I had been in Japan for three years or so, my back felt considerably better and my flexibility was noticeably improved, particularly when I cast my mind back to the "Rubber Man" era. All was progressing, I felt. An incident one day on my way to teaching a stretching class at the well-known "Clark-Hatch" gym in Tokyo soon dispelled my complacency. While walking across the car park (thinking about something else), I inadvertently stepped off a low curb — no more than three or four inches high — and felt a stabbing pain in my lower back. The sensation was so strong it literally took my breath away. I continued walking to the gym, and although my back did not feel "right," I taught the class. When I returned home that evening, I stripped off and looked at myself in the full-length mirror in the bathroom. Unbelievably, my hips seemed displaced so much to one side that the normal indentation of the waist had completely disappeared on one side, compensated for by double the amount on the other. I had trouble accepting the evidence of my eyes; I could not believe what I was seeing.

The following days suggested that this distortion was going to be with me for some time. I had treatment variously from my shiatsu teacher, a well-known local chiropractor, and in desperation yet another shiatsu teacher. None altered the displacement by any extent that I could see or feel. Worse still were their claims that they had not seen any equivalent problem in all their years of practice. I was so worried by this that I travelled four hours north of Tokyo to a famous chiropractor, but he could not help either. Very slowly, with careful stretching over a period of seven or eight weeks, my shape returned to normal. I now think that the incident resulted from an imbalance of too much flexibility and not enough strength, my body being predisposed to certain types of injury due to my leg-length difference.

I spent considerable time thinking about the physical structures involved. One chiropractor suggested that the distortion resulted from one hip bone (the ilium) moving with respect to the sacrum (in effect, driven upwards by the unexpected force of stepping off the curb onto my shorter leg while completely relaxed). This joint, particularly in men, is normally stable, the ligaments binding the sacroiliac joints on both sides of the pelvis are extremely strong, and the internal surfaces of the joint are irregular and fit each other. It is possible that all the hip abduction work (legs-apart stretching) I had been doing had upset the stability of the pubic symphysis (the joint where the pubic bones come together at the front of the pelvis), thereby permitting the much more stable sacroiliac joint to move. However, because the shape of the distortion appeared simply to be an extremely exaggerated version of the normal lateral curve in my lumbar spine induced by my leg-length difference, I thought this unlikely. Another chiropractor thought that my pelvis had "rotated" with respect to the lumbar spine, and that was the cause of the problem. When my teacher suggested that enough shiatsu treatment would even up the length of my legs, I felt that I needed to consider the problem in depth.

The apparently conflicting explanations I had been offered for the problem led me to think about possible relationships between information produced in different frameworks, and about standards of evidence. It seemed to me then (and seems so today) that there are various kinds of facts about the world, and that there are different expectations of reliability in relation to these facts. "Information" or "facts" depend crucially on the assumptions underlying the different frameworks giving rise to them, and these facts come bound together with indices of reliability. In this sense there are no certain facts (we might say, though, that some facts are very reliable and others less so), but comparison of explanatory range, assumptions, reliability indices and suitable constraints permit evaluation of different kinds of facts. In respect to my back problem, for example, it was not that one perspective was wrong and another right. Each perspective provided one window on the problem — a window that revealed a particular view.

These musings led me to think that, in respect to a health problem, we might conveniently divide the body into psychological and physical aspects for particular reasons, as western medicine ordinarily does. For example, the physical body might be considered in terms of a spectrum, from its least-alterable to most-alterable substances, as one way of deciding how to tackle a problem. One advantage of working with the physical aspects of a body (in contrast to the psychological) is that some of the cause and effect relationships are better known, and are often measurable. For instance, we know that the nerves of the body react most quickly to stress, followed shortly after by the muscles, then ligaments and tendons, and the slowest to change are the hardest substances in the body — the bones and teeth. How these substances manifest their reactions to particular stressors is well known. Knowing this about the body's organization, in respect to a problem like neck or back pain, we may affect the brain and the nerves using relaxation techniques, we may affect patterns of muscular tension, the results of stress, by using the stretching exercises, and we can strengthen the body in various ways against expected future stress.

This simplified approach may seem like a structural and engineering analysis, but the oriental medical "umbrella" permits useful association of aspects of the problem whose precise causal relationship is not clear. The oriental perspective allows greater freedom than the western medical approach, because it is a medicine of correlation rather than cause — it is a system of correspondence (Porkert, 1974). I will discuss the problems of causality further in chapter four. The essence of my approach is that, in respect of multicausal problems, analysis and treatment is better directed towards a desired outcome rather than trying to solve the problems of causality. This approach can avoid the pitfalls of symptomatic treatment.

Shoshin Center

In 1988 I opened the Shoshin Center, specializing in shiatsu. One of the four main forms of oriental medicine in the modern world, shiatsu applies periods of still, manual pressure on the acupuncture points for treatment following the yin-yang and the five element (or transformation) theories. Shiatsu was developed in Japan around the turn of the century by joining aspects of the Palmer chiropractic method with traditional Chinese massage, called anma in its Japanese form. Although I opened my center with the intention of practicing preventive medicine, the majority of patients were seeking a cure for a particular problem affecting them at the time. Although I stressed the medium and long-term effectiveness of lifestyle modification and the application of specific exercises for their problems, most patients preferred to return at three- or six-month intervals for treatment. By the end of the first year, it was clear that most patients wanted help with neck and back pain more than any other problems, and this pattern has continued to this day.

At any initial consultation in my clinic, I state that we should both know after a treatment or two whether my approach is likely to be effective, and I stress that any recommended exercise is an integral part of the treatment. It is essential to the success of any treatment that patients take responsibility for their problems. Most patients are agreeably sur

Table of Contents

CONTENTS
ILLUSTRATIONS
PREFACE
WHY THE INTEREST IN NECK AND BACK PAIN?

What is this book about?
What can I do?
Who should use this book?
How this book is set out
Cautions

INTRODUCTION
BACKGROUND TO THE APPROACH

Shoshin Center
Case studies from the clinic
Posture & Flexibility at the Australian National University
Contact address and e-mail

CHAPTER ONE
SELF-DIAGNOSIS

What is covered in this chapter?
Pelvic obliquity
How to determine if you have one hip lower than the other
i) one hip is lifted higher than the other
ii) both hips are lifted by the test, but one higher than the other
iii) both hips are lifted about the same
The heel insert
How thick should the insert be?
What if I make a mistake?
Other indicators of pelvic obliquity
How to determine whether muscular causes of problems like sciatica are present
How to determine your patterns of muscular tension

FLOW CHART FOR TESTING MUSCLE IMBALANCES
TEST AND EXERCISE CHECK LIST

How often should I stretch?
The general principles of good stretching, at a glance:

CHAPTER TWO
REHABILITATION STRETCHING EXERCISES

Limits
Static stretching
Ballistic stretching
The Posture & Flexibility approach to stretching
How to breathe
Benefits of warmth
Why photographs?

REHABILITATION
LOWER BACK EXERCISES

1. Seated forward bend
2. Seated side bend and rotation
3. Lying rotation
4. Partner-assisted lying rotation
5. Buttock and hip flexor
6. Seated hip
7. Lying hip
8. Table-top hip
9. Hip flexors
10. Trunk side bending
11. Hamstrings

MIDDLE BACK EXERCISES

12. Seated rotation
13. Upper back on all fours
14. Middle and upper back

NECK EXERCISES

15. Partner shoulder depress
16. Chin to chest
17. Neck side bend
18. Neck forward and side bend
19. Neck backward and side bend
20. Neck rotation
21. Chin-to-chest variations

CHAPTER THREE
PREVENTION

22. Advanced forward bend
23. Advanced forward and side bend
24. Advanced rotation
25. Advanced buttock and hip flexors
26. External hip rotator (piriformis)
27. Front thigh (quadriceps)
28. Backward bend over support
29. Backward bend from floor
30. Standing calf
31. Standing side bend
32. Lying side bend
33. Middle and upper back backward bend

STRENGTHENING EXERCISES

Matching training to expected demand
34. Abdominal curl
35. Abdominal curl over support
36. Back uncurl
37. Trunk rotation
38. Trunk rotation with weight

ADVANCED STRENGTHENING EXERCISE (PREVENTION)

39. Knee lift

PLANNING A TOTAL ROUTINE

Frequency of exercise
Sets and reps
Working habits
Speed of movements
The importance of rest
The place of aerobic exercise
Lifting things in everyday life
The daily six
For low back pain
For middle back pain
For upper back and neck pain
For wbole-body suppleness
Pointers to chapter four, causes, and chapter five, relaxation techniques

CHAPTER FOUR
THE CAUSES OF NECK AND BACK PAIN

Why do we suffer back pain?
Chiropractic and osteopathy
Oriental medicine
Acute pain
Chronic pain
Muscle tension as cause
Other factors contributing to neck and back pain
What is good posture?
Tests of leg-length inequality
What effects can uneven hips have on the body?
How thick should my heel lift be?
Is right- or left-handedness related to the problem?
Adding another layer to the argument
Shortcomings with the idea of cause
Workshop experiences
Choice of bed

CHAPTER FIVE
RELAXATION TECHNIQUES

Practical Stress Management seminars
Why relax?
Relaxation method
Guided visualization and healing the body
A script for relaxation and visualization

ACKNOWLEDGMENTS
REFERENCES

Further reading (annotated)

QUICK REFERENCE
ILLUSTRATIONS

Heel insert
Where am I sore?
The Contract-Relax (C-R) approach to stretching
Muscles stretched in exercise 1
Right hip in the intermediate position showing stretched muscles in exercise 5
Three ways the sciatic nerve may exit the pelvis
Psoas, iliacus (iliopsoas), and quadratus lumborum
Exaggerated lumbar curve caused by tight iliopsoas
Schematic showing quadratus lumborum, as stretched in exercise 10
Hamstring muscle from side; biceps femoris
The three hamstring muscles
Levator scapulae, and detail of suboccipitals
Front and side neck muscles
Possible entrapment of nerves by scalene muscles
Muscles of the front and inside of the leg
Muscles of the lower leg
Sciatic nerve runs down back of leg
Schematic of hip muscles affected in exercise 31
Upper body muscles, and changes accompanying aging
Why the conventional situp can injure the lower back
Class II lever
Exercise 36 strengthens the trunk in the necessary range of movement
Correct form in exercise 37
One theory of back weakness
The three curves of the spinal column act as a shock absorber
Schematic of spine, vertebral bodies and disc
Posterolateral (back-side) extrusion of intervertebral disc impinging on nerve root
Schematic showing significance of leg-length difference
Schematic of good posture
Effects of pelvic obliquity on the shape of spine
Simple model of possible effects of leg-length difference
Schematic of rowing
As leg extends, hip joint ligaments tighten around neck of femur

Introduction

PREFACE

WHY THE INTEREST IN NECK AND BACK PAIN?

It seems that everyone has suffered neck or back pain at some stage. Neck or back pain affects between 60% and 85% of people. Probably you are one of these people. In one study, researchers reported that 21% of patients experienced back pain in the 14 days preceding the study. Another study reported that at least 5% of all patient visits to the doctor are due to back pain.

Tremendous costs are involved. Neck and back pain account for half the worker's compensation payments in the United States and Australia, they are the single greatest cause of lost work time in both countries, and low back pain alone costs over $85 billion annually in the United States, about one-third of this amount being the direct costs of medical care. The 10% or so of patients who suffer chronic back pain account for 75% of Australia's rehabilitation and compensation payments. The social cost cannot be calculated -- back pain is the most frequent cause of inactivity among people under 45 years of age. In the U.S., Great Britain and Australia, the number of people disabled by these problems has increased exponentially since the 1970s, during a period of only modest population increase (Schwarzer, 1996; Rainville et al., 1996).

However, patients are not the only ones to suffer. Back pain has been described as "a wilderness across whose inhospitable terrain orthopedic surgeons, neurosurgeons, physiotherapists and, above all, general practitioners are doomed to travel" (Littler, 1983). Most doctors believe "there is little doubt that most cases are due to derangement of the intervertebral joint in associationnd step (the prevention phase) conditions all of the relevant parts of the body by using more advanced stretching exercises and later, by adding specific strengthening exercises, to provide a measure of protection for the future. In these two chapters, I shall present an approach to neck and back pain that is effective in practical terms and a later chapter considers the problem in theoretical terms, and will help you to make sense of the conflicting research on the problem.

Who should use this book?

This book is written for anyone who suffers recurring neck or back pain, or who wishes to avoid these problems. Recovery isn't quick or simple, but there aren't many other options either. Unless your back or neck problem is of the kind that can be treated effectively by surgery or drug therapy (probably less than 10% of the cases presented to general practitioners), you may have found that the range of options seems limited to avoidance of the activity thought to be the cause or treatment of the symptoms. If treatment is successful, your back will be returned to normal; that is, to its "preinjury" level of function -- consequently, there is no guarantee that the problem will not return. My aim is to present a unified and comprehensive self-help approach. For those fortunate enough not to have such problems, the approach will increase the suppleness and strength of your neck and back to reduce the likelihood of injury to these areas.

How this book is set out

The introduction sounds a more personal note than following chapters. It begins with a brief history of events which led me to my current approach, including a rather lengthy stay in Japan where I st udied Shiatsu and a number of traditional exercise systems. I consider the various exercise systems from which I derived my own, the courses called Posture & Flexibility, and Strength & Flexibility, currently taught at the Australian National University. My clinic in Canberra (the Shoshin Center) is mentioned, and I present some relevant neck and back pain case studies. The first three chapters include the self-diagnosis method, and the stretching and strengthening exercises -- these are the nuts and bolts of my approach.

Chapter one takes you through the self-diagnosis step-by-step. There is a flow-chart of the diagnosis method at the end of the chapter, and a page to photocopy. On this you fill out the results of the leg length tests and the functional flexibility tests. Fill it in as you go through the chapter. There is also an illustration of where pain may be experienced in the neck and back, and exercises likely to be useful are listed alongside.

Chapter two contains the basic pain-relieving and rehabilitation exercises; the first section describes exercises for the back, and the second describes exercises for the neck. These are the most important exercises in the book, and for most people are the only ones they need to do on a regular basis.

Chapter three details the preventive stretching exercises. These are designed to improve and balance your existing flexibility, and allow you to focus more closely on your problem areas with stronger techniques. The second part of chapter three outlines my approach to strengthening exercise, and details a set of graded strength exercises, from a minimal set suitable for doing at home through to more elaborate exe rcises for which some equipment is needed.

However, do not go straight to the exercises without reading the cautions section below. Inappropriate exercise may worsen your condition, and the nature of the problem is the best guide to selecting the exercises which are right for you.

You will get more out of the exercises if you have a reasonable working knowledge of the anatomy of the areas of interest. For this reason, useful functional anatomical information will be found together with the exercises. Organizing the book this way means that you do not need to go backwards and forwards between the exercises and the anatomical details upon which the exercises so crucially depend. As mentioned, much experience has shown that the actual locus of neck or back pain tends to be the muscles associated with the spine. As each muscle has a clearly definable function, this knowledge will help you locate the particular group concerned, and guide you to the best exercise. The book has been bound so it can be left open on the floor beside you, to enable you to check your form as you practice, and the practical sections include Notes (presented in a larger typeface than the text) that contain the most important details about how to do each exercise. These are arranged alongside the photographs for easy reference.

Chapter four discusses the various causes of neck and back pain, from a number of medical perspectives beginning with that of western medicine. One of the reasons for so doing is that western medicine has the most detailed understanding of anatomy, and this knowledge is fundamental to my approach. Another reason is that we are familiar with the western medical perspective -- it i s the medicine of our culture. This chapter includes a brief consideration of chiropractic and osteopathy because neck and back pain is the main concern of these practitioners. Oriental medicine and some of the bodywork schools are also considered. Acute and chronic pain are treated separately, and mention is made of additional contributing factors. The chapter sounds a note on the limitations of the very idea of cause with respect to common illnesses, and offers a rationale for my functional approach. The experiences of the workshops we have been running for individuals and practitioners are presented, and consideration is given to choice of beds and pillows.

Chapter five provides a justification for including relaxation techniques as part of the larger approach to overcoming neck and back pain. It discusses practical stress management briefly, outlines the current understanding of stress and its effects on the body, and ends with an easy-to-learn method for relaxation. Useful guided visualization techniques for speeding up the heating process are included in the relaxation script.

Cautions

Before you begin, some notes of caution must be sounded. If you are undergoing some form of treatment at the moment, you must discuss the exercises presented in the book with your practitioner before beginning. It is a matter both of courtesy and safety -- some of the exercises may be inappropriate for your condition. Further, embarking on a course of exercises that have not been examined or approved by your practitioner may void any compensation to which you may be entitled. I have written this book in good faith, but I cannot personally supervise your performance of the movements, and t herefore cannot accept any responsibility for errors you make. Neither can I know the particular details of a condition you may have -- this is your responsibility. These aspects necessitate the greatest caution on your part -- the fact that thousands of people have benefited from this system is no guarantee that you will. Consequently you must approach the exercises with caution, and you must monitor the effects closely.

Next,do not refer only to the photographs. You must read the sometimes lengthy descriptions that accompany them. Information vital to safety is contained in the text, along with descriptions of how to press or pull certain parts in certain ways. It is not possible to understand the exercises only by looking at the photographs.

The next caution concerns the order in which the exercises are presented. In most cases the easiest and safest versions of any movement are shown first; these versions are marked easiest in the text. More difficult versions are labeled intermediate; the most difficult are labeled advanced. This is the order in which you should attempt them. Even if you know that you can do a more difficult version, begin with the easiest one. You can always learn something about the way your body works from doing an easier rather than a more difficult version of an exercise, simply because you can concentrate more on your responses to a movement rather than its complexities. Additionally, the easier versions are a useful warm-up for the later ones.

Lastly, I wish to discuss some practical cautions. Exercise in the evenings rather than the mornings as the body is more supple then. You must not exercise within an hour and a half of eatin g. It is best to exercise in the hour before you eat the evening meal. Always go to the toilet before beginning. Wear clothing that both keeps you warm, and permits free movement. Some of the exercises require a strap, strong towel, or some other method of holding a part of the body, so have something handy. For the first few weeks or months, I suggest that you stretch only twice a week, which may be increased to three times as you improve. The text includes specific instructions on the few exercises I recommend be done daily to relieve the body of the effects of the day's stress. More of this later.

The following caution may be self-evident, but permit me to labor a vital point. You must imitate the form of the exercises demonstrated, not my performance of them. The purpose of the precise descriptions and photographs is so that you can place yourself in the positions I have found to produce the best results. You then proceed with the stages of the movements only until you feel the stretch I describe, and stop at that point. In the demonstration of the movement, I may have taken the particular limb further in the range of movement than you can, but this is immaterial. (You may well be able to stretch further than I in some exercises, too.) The sole purpose of an exercise is to feel a stretch in the right place. Please keep this in mind -- most teaching of stretching exercise fails on this crucial point.

The most general, and important, caution I have saved until last. It is that you must listen to what your body tells you while you are doing the movements -- no one else can do this for you, not even the best teacher. Very early in your practice you must learn t he essential difference between the right kind of stretch sensation and going too far. For this reason, I urge you to do too little rather than too much in the beginning -- realizing the difference too late will be painful, and possibly dangerous. Remember the old adage: "Rome was not built in a day."

The Introduction provides you with the background to the approach advocated in the book. If you prefer, you may go straight to chapter one, the self-diagnosis method, and return to the Introduction at a later time.

INTRODUCTION

BACKGROUND TO THE APPROACH

In this introduction, I should like to give you some personal details, which I hope will both be interesting and give you some insight into what led me to develop the methods presented in the rest of the book.

During the early 1980s, I was a television director and a struggling athlete. I trained for the 800- and 1500-meter races, the so-called middle distance events. Directing the Australian Broadcasting Commission's nightly current affairs program Nationwide was stressful enough on its own; together with all the running training -- we ran 100 miles (160 km) a week in the winter months -- I now think that I was asking too much of myself. I used to hold a tremendous amount of tension in the middle back muscles. Despite physiotherapy and chiropractic treatments, the problem never really improved beyond temporary relief.

Some sort of insight occurred one day when I bent down to touch my toes after an interval training session at Sydney University. At full stretch my fingers came a few inches below my knees, and that was with my back bent like a bow. Someone t ook a photograph of me doing this, and it ended up on the wall at the H. K. Ward gym (where many of the local track and field athletes did their weight training), suitably inscribed "Rubber Man."

The next insight occurred when I was using the seated heel raise machine (from the seated position a padded bar over the knees is lifted by the feet to strengthen soleus, one of the two calf muscles). I placed my feet evenly on the footrest and positioned my heels level with each other. One knee contacted the support bar. The other was a full centimeter or so lower. Naturally, my first thought was that the machine had been bent by one of the serious bodybuilders using too much weight. I looked at it carefully, got a tape measure from the attendant at the front desk, and after careful checking decided that it was straight. Only then did the possibility that I might not be straight occur to me. Careful measurement revealed that my right leg from knee to heel was noticeably shorter than my left. I mention this only to highlight the point that we resist the notion that there might be something less than ideal in our own physical makeup, but consideration of all possibly relevant information is essential if we wish to overcome our problems.

Once I had accepted the difference (in fact my right leg is shorter by about three quarters of an inch or two centimeters, evenly divided between the upper and lower leg), I began to think about the effects this structural asymmetry might have caused. I had trained for both Olympic and power lifting for years before losing quite a deal of weight to become a middle distance runner. I realized that years of weight training adapted my body to two major stresses -- the stresses of the training itself, and the asymmetric distribution of those forces as resolved in my particular body, so not only had I become extremely tight in the process but had also developed an individual pattern of flexibility. I began "limber" classes at a Sydney dance studio, and these patterns became only too clear. I also quickly realized that the approach adopted in these classes was not efficient for teaching adults how to become flexible. The young students were very supple and had become flexible while they were still children. What looked like stretching classes were really preparation, or an extended warmup for their ballet classes later in the day. My experience there made me think about the differences between adults' and children's bodies, and how one might improve on the standard approaches to the problem of how to teach adults to become flexible.

At this time, I experimented with lifts of various thicknesses in my right shoe. The difference it made to running was immediately apparent. The shooting pains in between the shoulder blades experienced in the finishing stretches of my races all but disappeared, and on using the insert the first time, I immediately felt more balanced walking and running.

During the late 1970s I attended yoga classes at various places around Sydney. I found the classes relatively inflexible in their teaching approach: students lined up in neat rows and little dialogue. The strict atmosphere often discouraged questions at the very time one needed assistance. I was disturbed by the tendency for some teachers to accept the pronouncements of their own teachers uncritically. Guru worship was commonplace, and many teachers had adopted the mannerisms and ap horisms of their own gurus. What I subsequently learned to be the correct form of various poses was being distorted by many students in their attempt to imitate the teacher through simple inflexibility. Questions like, "why do we do it this way?" were left unanswered, or deflected with replies like "tradition," or "that's the way the posture is taught by my teacher," and so on. I met few teachers who had more than a passing acquaintance with anatomy -- the one aspect of western medicine normally unquestioned by the alternative healing arts. Of course, these were my particular experiences at the time; much has changed since these early days, and anatomical knowledge is now emphasized in contemporary yoga teaching.

During this period I also resumed martial arts training, and so did the kind of stretching usually employed in these arts during the warmup -- vigorous dynamic movements, assisted by a partner or an instructor, and all over in 15 minutes before the real training began. No attention was paid to form in the exercises, and I injured myself a number of times using this approach. On one occasion, I pulled a groin muscle (one of the adductors) that took nine or ten months to heal and which was subsequently injured at another training session.

I had my thirtieth birthday in Japan. I had had enough of television, and decided to go to the source for martial arts. I was dismayed to find the same approach to stretching used there too. I found disbelief on the part of teachers who could not accept that someone who had trained for ten years or so was not perfectly flexible. They had no effective suggestions on how to become more flexible. They had all done the usual stretching as children (us ual in Japan, anyway), started their martial arts training at an early age and consequently did not need to know how to make an adult flexible. The severe training I went through (I was a live-in student, called an uchi deshi) made my back muscles even tighter. After nearly a year and a half of this life, I found myself unable to recover from an illness that alternated between a cold and influenza for six months. A friend had been studying a form of oriental medicine for a year or so (shiatsu) and, sick of being kept awake at night when I visited, he suggested that I go to see his teacher.

It was a revelation. Never have I let anyone hurt me so much. I was holding a tremendous amount of tension in the muscles of my body, and all the places he worked on, including my back, were incredibly tender to touch. The sensei told me that although my body was strong it was holding excessive tension everywhere, which he felt was the result of the stress of the work I used to do plus the effects of the rigorous current training. He would poke my body and say in English, "Too hard, too hard." I confess I was skeptical of a treatment that consisted merely of maintaining a leaning pressure on various places using the elbows and thumbs mainly, together with a few simple stretches and manipulations of the bones of the body. However, I started to feel better that same day, and by the time of the next treatment (a week later) the cold had gone. It was at the conclusion of the second treatment that I was introduced to a woman who would change my way of thinking about flexibility. Ms. K-- was a diminutive Japanese woman around 35 years old. She was the translator for the shiatsu classes presented f or foreigners at the center. Sensei mentioned that I was interested in becoming more flexible. Ms. K--'s way of getting to the floor for this conversation involved sliding through the side splits into front splits, then lifting herself into seiza, the normal Japanese way of sitting on one's feet. It certainly got my attention.

Ms. K-- and I were to do considerable work together during the ensuing few years on flexibility and shiatsu, as I became a student. She was the sole surviving shihan (senior teacher) of an exercise method called Jikyo Jutsu. Roughly translated, this means "self-help method." Like Tai Chi, it is based on meridian theory, the practice of which is designed to "harmonize energy flow" around the body and promote internal health, in much the same way as shiatsu. This improvement in internal health is said to be responsible for the increase in flexibility that follows. In other words, the acquisition of flexibility was deemed to be a side effect of health. Quite different to our western approach, I thought. The exercises themselves were an interesting mixture of dynamic stretching movements and pressure point therapy. In time I was awarded a shodan (a "first degree" black belt). "Sho" is the character for "beginning," and unlike other parts of the world where a black belt is often regarded as a pinnacle of achievement, in Japan it signifies a starting point.

Part of the learning process of shiatsu involves receiving treatment from one's teacher. I received treatment for a year or more on a fortnightly basis, did the Jikyo Jutsu, and taught and attended yoga classes in Tokyo. By the time I had been in Japan for three years or so, my back felt considerably better and my flexibility was noticeably improved, particularly when I cast my mind back to the "Rubber Man" era. All was progressing, I felt. An incident one day on my way to teaching a stretching class at the well-known "Clark-Hatch" gym in Tokyo soon dispelled my complacency. While walking across the car park (thinking about something else), I inadvertently stepped off a low curb -- no more than three or four inches high -- and felt a stabbing pain in my lower back. The sensation was so strong it literally took my breath away. I continued walking to the gym, and although my back did not feel "right," I taught the class. When I returned home that evening, I stripped off and looked at myself in the full-length mirror in the bathroom. Unbelievably, my hips seemed displaced so much to one side that the normal indentation of the waist had completely disappeared on one side, compensated for by double the amount on the other. I had trouble accepting the evidence of my eyes; I could not believe what I was seeing.

The following days suggested that this distortion was going to be with me for some time. I had treatment variously from my shiatsu teacher, a well-known local chiropractor, and in desperation yet another shiatsu teacher. None altered the displacement by any extent that I could see or feel. Worse still were their claims that they had not seen any equivalent problem in all their years of practice. I was so worried by this that I travelled four hours north of Tokyo to a famous chiropractor, but he could not help either. Very slowly, with careful stretching over a period of seven or eight weeks, my shape returned to normal. I now think that the incident resulted from an imbalance of too much flexibility and not enough strength, my body being predisposed to certain types of injury due to my leg-length difference.

I spent considerable time thinking about the physical structures involved. One chiropractor suggested that the distortion resulted from one hip bone (the ilium) moving with respect to the sacrum (in effect, driven upwards by the unexpected force of stepping off the curb onto my shorter leg while completely relaxed). This joint, particularly in men, is normally stable, the ligaments binding the sacroiliac joints on both sides of the pelvis are extremely strong, and the internal surfaces of the joint are irregular and fit each other. It is possible that all the hip abduction work (legs-apart stretching) I had been doing had upset the stability of the pubic symphysis (the joint where the pubic bones come together at the front of the pelvis), thereby permitting the much more stable sacroiliac joint to move. However, because the shape of the distortion appeared simply to be an extremely exaggerated version of the normal lateral curve in my lumbar spine induced by my leg-length difference, I thought this unlikely. Another chiropractor thought that my pelvis had "rotated" with respect to the lumbar spine, and that was the cause of the problem. When my teacher suggested that enough shiatsu treatment would even up the length of my legs, I felt that I needed to consider the problem in depth.

The apparently conflicting explanations I had been offered for the problem led me to think about possible relationships between information produced in different frameworks, and about standards of evidence. It seemed to me then (and seems so to day) that there are various kinds of facts about the world, and that there are different expectations of reliability in relation to these facts. "Information" or "facts" depend crucially on the assumptions underlying the different frameworks giving rise to them, and these facts come bound together with indices of reliability. In this sense there are no certain facts (we might say, though, that some facts are very reliable and others less so), but comparison of explanatory range, assumptions, reliability indices and suitable constraints permit evaluation of different kinds of facts. In respect to my back problem, for example, it was not that one perspective was wrong and another right. Each perspective provided one window on the problem -- a window that revealed a particular view.

These musings led me to think that, in respect to a health problem, we might conveniently divide the body into psychological and physical aspects for particular reasons, as western medicine ordinarily does. For example, the physical body might be considered in terms of a spectrum, from its least-alterable to most-alterable substances, as one way of deciding how to tackle a problem. One advantage of working with the physical aspects of a body (in contrast to the psychological) is that some of the cause and effect relationships are better known, and are often measurable. For instance, we know that the nerves of the body react most quickly to stress, followed shortly after by the muscles, then ligaments and tendons, and the slowest to change are the hardest substances in the body -- the bones and teeth. How these substances manifest their reactions to particular stressors is well known. Knowing this about the body's organiza tion, in respect to a problem like neck or back pain, we may affect the brain and the nerves using relaxation techniques, we may affect patterns of muscular tension, the results of stress, by using the stretching exercises, and we can strengthen the body in various ways against expected future stress.

This simplified approach may seem like a structural and engineering analysis, but the oriental medical "umbrella" permits useful association of aspects of the problem whose precise causal relationship is not clear. The oriental perspective allows greater freedom than the western medical approach, because it is a medicine of correlation rather than cause -- it is a system of correspondence (Porkert, 1974). I will discuss the problems of causality further in chapter four. The essence of my approach is that, in respect of multicausal problems, analysis and treatment is better directed towards a desired outcome rather than trying to solve the problems of causality. This approach can avoid the pitfalls of symptomatic treatment.

Shoshin Center

In 1988 I opened the Shoshin Center, specializing in shiatsu. One of the four main forms of oriental medicine in the modern world, shiatsu applies periods of still, manual pressure on the acupuncture points for treatment following the yin-yang and the five element (or transformation) theories. Shiatsu was developed in Japan around the turn of the century by joining aspects of the Palmer chiropractic method with traditional Chinese massage, called anma in its Japanese form. Although I opened my center with the intention of practicing preventive medicine, the majority of patients were seeking a cure for a particu lar problem affecting them at the time. Although I stressed the medium and long-term effectiveness of lifestyle modification and the application of specific exercises for their problems, most patients preferred to return at three- or six-month intervals for treatment. By the end of the first year, it was clear that most patients wanted help with neck and back pain more than any other problems, and this pattern has continued to this day.

At any initial consultation in my clinic, I state that we should both know after a treatment or two whether my approach is likely to be effective, and I stress that any recommended exercise is an integral part of the treatment. It is essential to the success of any treatment that patients take responsibility for their problems. Most patients are agreeably surprised to be so actively involved in the outcome of the treatment. For many, it is a new experience.

Case studies from the clinic

I should like to mention the experiences of a few patients briefly, for they illustrate my method at work and the types of problems for which it might prove helpful.

The first concerns a young (21) male rower. He came to me complaining of back pain caused, he said, by lifting a rowing "shell" (boat) out of the water. These were the only details he gave me. When I examined him, I found a marked scoliosis (lateral curvature of the spine), with the right shoulder carried high on the outside of a left-facing concavity. He was right-handed and, as you might expect, the development of the muscles of the right side of the spine was noticeably greater than the left. He rowed on the left side of the boat so that, in addition to the uneven development caused by t he scoliosis, he displayed an extra muscular development caused both by being righthanded, and the fact that the right shoulder was moving through a greater arc than the left (due to the rotation that sweep rowing adds to the extension of the basic rowing movement). Although he complained of low back pain when we first spoke, I asked him whether his middle and upper back also troubled him. As this was so, my first suggestion was for him to train on the other side of the boat once or twice a week and to report back.

Turning then to his low back pain, I performed a structural examination and the usual tests of functional flexibility, concentrating on a comparison of left and right, as will be developed below. There were marked differences in all the relevant tests, but no discernible leg-length difference. I enrolled him in a beginners' stretching class, and after a couple of months he reported that the pain had gone. We then embarked on a strengthening program together, and I was fascinated to see that although a nationally competitive rower, he had very poor strength in the trunk muscles. Considering the excellent development of the upper and lower body, I considered it likely that this lack of strength was a contributing cause of his problems, because his waist would not be capable of transmitting the strength of the legs and hips to the arms without distortion. To address this, I developed the basis of the waist strengthening program offered later in this book. After concentrating on the stretching and strengthening exercises for about eight months, he competed in the annual "Nationals" for rowers, recording the third-highest ergometer score without a trace of back pain. Today, some five years l ater, there has not been any recurrence of the original problem.

The extraordinary aspect of this case was that after the Nationals, the young man's doctor revealed to me that when the rower "hurt his back" the year before while lifting the boat out of the water, he had in fact suffered a "massive extrusion of the L5-S1 intervertebral disc, so much so that he had displayed various neurological deficits" at that time. As you will see, neurological deficits are considered hard evidence of nerve impingement and serious pathology. Even in the case of demonstrable pathology -- of the sort often requiring surgery -- the approach I advocated was successful. I realize that this is a highly unusual case and perhaps is evidence only of the superior recuperative capacity of a top athlete. Nonetheless, providing one has the support of one's doctor, I urge a conservative "wait-and-see" approach initially, followed by cautious stretching exercise, and followed up with strengthening exercises as the condition improves.

Another interesting case began with a telephone call from a man desperate to return to work. Originally a case of acute onset back pain, the treatments he sought were not successful and the pain had become chronic over an eighteen-month period. His complaint included the original back pain and referred pain down one leg. The rearward curve in his lumbar spine seemed pronounced. His radiographer's report noted a "right-facing concavity of the lumbar spine" but normal joint structures and no disc abnormalities. When I tested this man, I found a leg-length difference of about half to three-quarters of an inch (12-15 millimeters), and a commensurate pattern of flexibility. The referred pain w as experienced in the longer leg. A heel insert and just three stretching exercises had this person back at his job with much reduced discomfort. He called me recently to let me know that he was still well after a year. He said that, provided he did the exercises once or twice a week, he had no problems. In his case, I believe that the original trauma (he had slipped walking down the stairway from a local-service light plane two years previously) had resulted in a muscle injury that, due to the leg-length difference, had not had a chance to recover fully. The pain he suffered appeared to be located in the quadratus lumborum muscles on the side of the longer leg. Accordingly, a heel lift of three-eighths of an inch (five millimeters) and appropriate stretching exercises were prescribed. In his example, the side-bending with legs apart stretch provided immediate relief from the back pain itself, and a comparison of the hip flexors (muscles that lift the thigh to the chest) revealed one to be very much tighter than the other. Stretching this muscle group made a visible difference to the shape of his lower back within a couple of weeks.

Of course, not all case studies document these kinds of successes. It would be remiss of me not to mention a failure or two as well, in the interests of admitting the limits of this approach. A young woman saw me about five years ago with back pain, which her doctor had said was caused by a partial extrusion of the nucleus pulposus, the gelatinous core of the intervertebral disc. He advised surgery, but because her symptoms had not progressed to the stage of displaying serious neurological deficits, she felt that a conservative, exercise-based appr oach would be worth trying. I treated her a couple of times with shiatsu and, although we identified the exercises that gave her relief at the time and whose effects lasted a few days or so, eventually the pain became so intense that she had to have the operation. About eight months was needed for her to determine the outcome of the operation, which was successful. She continues to do the exercises from time to time, and reports that her back has much improved. Her surgeon remarked to her that her rapid recovery from the operation (she was walking around normally two weeks later) was likely due in part to the suppleness she acquired doing the exercises before the operation.

The final case study I saved until last because in one sense it is the most dramatic. A small middle-aged woman came to me complaining of "excruciating" back pain. She had not responded to any treatment and she seemed to have tried them all. Back pain had plagued her for 14 years, she said. Her job entailed travelling extensively, and she felt that the many hours she spent in the car each week were contributing to her problem. As an aside, I must note that the majority of patients know far more about their condition than most practitioners seem to give them credit for. She had bought an expensive after-market seat for her car, featuring an adjustable lumbar roll and firm side supports. The pain had not improved with this modification, but neither had it worsened over the previous year. The pain was so intense at night that her physical relationship with her husband was nonexistent. Needless to say, both were strongly affected by the illness. I began with a leg-length test which revealed a small (few millimeters) difference. Hip flexion and hamstring flexibility were within normal limits and not significantly dissimilar, I thought. When I tested her for hip flexor (iliopsoas) tightness, quite a different picture emerged. One hip flexor showed the normal range of movement. Coincidentally, I had begun this test sequence with this leg. After I tested the other, which was so tight that the leg would not move past the mid-line of the body before doing a Contract-Relax (C-R) stretch, she stood up next to the massage table she was using for support. She had a very peculiar took on her face -- fear mixed with shock. I asked her what was wrong. She replied that this instant in time was the first time in 14 years that her back was not "killing" her. This state of affairs continues to this day, and she calls me every six months or so to let me know how she is doing.

I know that this particular example may appear to border on the incredible, perhaps even unbelievable. I could not accept it myself at the time, and months after the consultation I was sure that any day I would receive a call from her to say that her old problem had returned. I can only surmise that some fibers of the hip flexor group were extraordinarily tight and, in addition to their contribution to the extreme tension in the lumbar region, were causing the rotation of one vertebra with respect to its neighbors, and hence the pain. It is also likely that the enforced flexion of the hip joint (brought about by all those years spent in a car) may have contributed significantly to this aspect of the problem.

Posture & Flexibility at the Australian National University

When I returned from Japan and enrolled at the ANU, I decided to start an exercise class. My main motive was to ensure that I did enough stretching exercise myself each week. From one class per week in 1987, the course (named Posture & Flexibility) has grown to 20 classes per week in 1998. In addition, we teach another five to seven classes called Strength & Flexibility, where the emphasis is on accelerated strength acquisition techniques. I have taught all the teachers myself, and they come from diverse backgrounds. All attend the weekly advanced class, where information is shared and new techniques tested.

The exercise forms that have strongly influenced my present work are Yoga (hatha yoga, and more particularly the Iyengar style) and two traditional Japanese forms (Makko Hoo and Jikyo jutsu).

None is complete in my opinion and I have taken liberally from all three. Where I have identified significant lack in all three forms (for example, specific neck exercises), I have relied on my anatomical understanding to develop an appropriate movement. Recognizing that these traditional exercise forms have objectives other than the acquisition of flexibility, I have taken from anyrelevant form (including dance and gymnastics) solely on the basis of furthering the goal of becoming more flexible. In this way, the goal became a de facto framework for relating forms which technically or historically were unrelated and whose traditional adherents (as often as not) would not like to see related. All exercises presented have been tested on thousands of patients and students.

Very early in my attempts to formulate an approach to stretching exercise, I realized that the conventional approaches to teaching exercise also had se rious shortcomings. As mentioned earlier, of all the exercise forms I've experienced, yoga is closest to being complete in its stretching and strengthening effects but approaches to teaching it vary from insufficiently precise to doctrinaire. I also found that some of the recommendations for poses (like the lotus) made in the most reputable of textbooks are potentially dangerous, or simply wrong when considered from an anatomical perspective. Here I am not speaking of the putative effects of a pose, which often defy explanation in the scientific framework. I am talking of advice like the need to "endure excruciating pain in the knees" when practicing padmaasana (the lotus pose). The point here is that this kind of pain will only be felt if the hip joint has insufficient external rotation to permit the movement. My view is that a number of partial poses that foster this capacity in the hip joints should be used before attempting the pose, because it is potentially dangerous to use the knees in the strongly flexed position to generate rotational forces in the hip. This is because there is a real danger of overstretching the knee ligaments, which are maximally exposed in this position, and much of the strength of the knee in daily life derives from ligament strength.

After teaching stretching exercise for more than fifteen years, I suppose the most obvious conclusion I have reached is that age is no barrier to improvement. The older student usually progresses at a slower rate than a younger one, but the difference is nowhere as great as one might expect. I have also noticed that improvement in flexibility is slower in the initial weeks and months of a new stretching routine than are the result s of a comparable amount of time spent on strength or aerobic training. However, improvement and its consequent effects are relative. Any improvement in flexibility -- no matter how small in absolute terms -- is experienced as a major positive event by the person concerned. Even in the most stubborn case, the absolute improvement in a particular aspect of flexibility is about 10% in a year, and the sensations of daily life are changed significantly in the person enjoying this improvement on a daily basis.

Feedback from many students over the years permits me to make some concluding remarks about the relation of practice and the outcomes of illness or injury. Students report a range of benefits. When pressed for detail, they may reply that odd random aches or pains have disappeared. Some say that movement in daily life has taken on a quality of pleasure that was not previously present. However, others have been far more specific about effects. Many people come to the classes because of the kinds of neck or back pain rife among academics and students, so that the next most commonly heard remark is that the original complaint is much improved or "cured" completely. This is also true (although to a lesser extent, admittedly) for more insidious complaints such as repetitive strain injury (RSI), or occupational overuse syndrome (OOS), where the neck, shoulder and arm exercises have proved beneficial in the majority of cases. It should be noted that in these kinds of illnesses lifestyle modification is usually required for best results. As most academics and students are unable or unwilling to do this for various reasons, the exercise classes are often used as a means of coping with the problem.

Contact address and e-mail

I am very interested in people's experiences of using the approaches detailed in the book, and this edition has benefitted from the suggestions of a great many readers. To that end, I have provided my work address for correspondence. Any suggestions or criticism will be considered and incorporated with acknowledgment in future editions.

Kit Laughlin
LPO Box 159
Australian National University
Canberra, ACT 2601
AUSTRALIA
e-mail: [e-mail]

Copyright © 1995, 1996, 1998 by Kit Laughlin