Back to basics
Monday February 13, 2012
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Esther Gokhale, of Palo Alto, Calif., began suffering from debilitating lower back pain during her first pregnancy, and the pain only intensified after her baby was born. Two months later, she was so uncomfortable she walked around her neighborhood in the middle of the night every two hours to alleviate the pain. She couldn't carry her baby, was forced to nurse lying down and was advised to have no more children.
She tried chiropractics, acupuncture, physical therapy and finally back surgery for a severely herniated disc, but 12 months after the surgery, her pain returned. Devastated, Gokhale (pronounced go-clay) began researching medical literature about back pain in other countries.
"It didn't make sense for an athletic woman in her mid-20s to be so afflicted by a serious life-crippling problem," Gokhale said. "I knew there was something to be learned from nonindustrialized cultures, and my research during my travels abroad confirmed that these people suffer from much less back pain."
After years of studying other movement methods and traveling in Third World countries, she created the "Gokhale Method," which teaches students how to sit, stand and walk the way our ancestors did. As a result of using these techniques, Gokhale has been pain-free for 20 years, she said.
For physical therapists like Cheri Boeckmann, PT, who integrates the Gokhale Method into her practice, combining alternative approaches with traditional physical therapy when treating back pain translates to better outcomes for patients. Whether it be the Gokhale Method, Pilates or the Alexander Technique, PTs who use these strategies suggest in many cases, they are able to reduce back pain that otherwise would have seemed hopeless.
Primal posture
Boeckmann, a PT with Lovingston (Va.) Physical Therapy, stumbled upon the Gokhale Method several years ago when a patient handed her Gokhale's book, "8 Steps to a Pain-Free Back."
"It made so much sense to me," Boeckmann said. "I had spent a couple of years in Third World countries and had a sense that they moved differently. People of all ages could squat for long periods of time and walk with heavy baskets on their heads, and Esther clarified what I had sensed for a long time."
Gokhale's book cites studies such as a literature review published in Spine in 1997 that found low back pain was at least twice as common in high-income countries as in low-income countries. To learn more, Boeckmann attended the Gokhale Method Foundation's weekend training courses in 2009 and then a seven-day immersion course to become a qualified Gokhale Method instructor. One of the fundamental concepts Boeckman said she learned was the importance of tipping the pelvis forward in an anteverted position, rather than encouraging a tucked or retroverted pelvis. If the pelvis is retroverted, then the gluteal muscles are at a mechanical disadvantage and will become weak, Boeckmann said.
Gokhale promotes a J-shaped spine — rather than the traditional S shape — to lengthen the spine and decompress the discs. This J shape is part of what Gokhale defines as primal posture, and her techniques include "stretchsitting," "stretchlying" and "glidewalking" to promote this posture while sitting, sleeping and walking.
Stretchsitting is a method of sitting which puts the back into gentle traction. Stretchlying is a technique that elongates the spine while someone is lying down. Glidewalking is walking with smooth forward propulsion, challenging the muscles of the lower body and sparing the weight-bearing joints throughout the body.
"My frustration before I used this method was that I was not getting the results I wanted," Boeckmann said. "I am seeing better outcomes and I feel more comfortable where I am taking people. This method really gives a simple plan to teach people how to restructure their bodies."
To study the effectiveness of this method, Haleh Agdassi, MD, at the Palo Alto Medical Foundation in California plans to launch a study in April focused on the outcomes of patients with low back pain who learned the Gokhale Method after traditional physical therapy failed.
Pilates as therapy
Like Gokhale, Tyra Malmborg-O'Kelley, MPT, started searching for alternative methods of treating low back pain when traditional approaches failed to mitigate her pain. After delivering her second child, she suffered from acute SI-low lumbar pain. She tried lumbar stabilization and sought out a fellow PT for manual therapy but still had unpredictable moments of acute pain.
A friend suggested she try Pilates, and she was surprised when after a dozen one-on-one sessions with a certified Pilates instructor, her back pain significantly improved. The techniques were so compelling she decided to become a certified Pilates instructor and incorporate the techniques into her PT practice.
"Pilates is different than traditional PT in that we focus on eccentric contraction rather than concentric contraction," said Malmborg-O'Kelley, co-owner of Integrated Rehabilitation Group throughout the state of Washington. "By engaging the muscles around the trunk eccentrically, patients learn to use muscles properly to stabilize the spine, pelvis and shoulder blades."
Pilates training has changed not only the types of exercises she uses, but also the parts of the body on which she focuses.
"Pilates has taught me to look at the body as a whole," she said. "In the past, if I was treating a lumbar problem, I would look at the root of problem, such as a bulging disc, and work around this area. Now, I look at it more globally. I explore the reason why a patient may have a bulging disc. A lot of it comes down to abnormal mechanics, and abnormal mechanics are often caused by weak abdominal muscles, which can destabilize the spine and create pain."
She tried chiropractics, acupuncture, physical therapy and finally back surgery for a severely herniated disc, but 12 months after the surgery, her pain returned. Devastated, Gokhale (pronounced go-clay) began researching medical literature about back pain in other countries.
"It didn't make sense for an athletic woman in her mid-20s to be so afflicted by a serious life-crippling problem," Gokhale said. "I knew there was something to be learned from nonindustrialized cultures, and my research during my travels abroad confirmed that these people suffer from much less back pain."
After years of studying other movement methods and traveling in Third World countries, she created the "Gokhale Method," which teaches students how to sit, stand and walk the way our ancestors did. As a result of using these techniques, Gokhale has been pain-free for 20 years, she said.
For physical therapists like Cheri Boeckmann, PT, who integrates the Gokhale Method into her practice, combining alternative approaches with traditional physical therapy when treating back pain translates to better outcomes for patients. Whether it be the Gokhale Method, Pilates or the Alexander Technique, PTs who use these strategies suggest in many cases, they are able to reduce back pain that otherwise would have seemed hopeless.
Primal posture
Boeckmann, a PT with Lovingston (Va.) Physical Therapy, stumbled upon the Gokhale Method several years ago when a patient handed her Gokhale's book, "8 Steps to a Pain-Free Back."
"It made so much sense to me," Boeckmann said. "I had spent a couple of years in Third World countries and had a sense that they moved differently. People of all ages could squat for long periods of time and walk with heavy baskets on their heads, and Esther clarified what I had sensed for a long time."
Gokhale's book cites studies such as a literature review published in Spine in 1997 that found low back pain was at least twice as common in high-income countries as in low-income countries. To learn more, Boeckmann attended the Gokhale Method Foundation's weekend training courses in 2009 and then a seven-day immersion course to become a qualified Gokhale Method instructor. One of the fundamental concepts Boeckman said she learned was the importance of tipping the pelvis forward in an anteverted position, rather than encouraging a tucked or retroverted pelvis. If the pelvis is retroverted, then the gluteal muscles are at a mechanical disadvantage and will become weak, Boeckmann said.
Gokhale promotes a J-shaped spine — rather than the traditional S shape — to lengthen the spine and decompress the discs. This J shape is part of what Gokhale defines as primal posture, and her techniques include "stretchsitting," "stretchlying" and "glidewalking" to promote this posture while sitting, sleeping and walking.
Stretchsitting is a method of sitting which puts the back into gentle traction. Stretchlying is a technique that elongates the spine while someone is lying down. Glidewalking is walking with smooth forward propulsion, challenging the muscles of the lower body and sparing the weight-bearing joints throughout the body.
"My frustration before I used this method was that I was not getting the results I wanted," Boeckmann said. "I am seeing better outcomes and I feel more comfortable where I am taking people. This method really gives a simple plan to teach people how to restructure their bodies."
To study the effectiveness of this method, Haleh Agdassi, MD, at the Palo Alto Medical Foundation in California plans to launch a study in April focused on the outcomes of patients with low back pain who learned the Gokhale Method after traditional physical therapy failed.
Pilates as therapy
Like Gokhale, Tyra Malmborg-O'Kelley, MPT, started searching for alternative methods of treating low back pain when traditional approaches failed to mitigate her pain. After delivering her second child, she suffered from acute SI-low lumbar pain. She tried lumbar stabilization and sought out a fellow PT for manual therapy but still had unpredictable moments of acute pain.
A friend suggested she try Pilates, and she was surprised when after a dozen one-on-one sessions with a certified Pilates instructor, her back pain significantly improved. The techniques were so compelling she decided to become a certified Pilates instructor and incorporate the techniques into her PT practice.
"Pilates is different than traditional PT in that we focus on eccentric contraction rather than concentric contraction," said Malmborg-O'Kelley, co-owner of Integrated Rehabilitation Group throughout the state of Washington. "By engaging the muscles around the trunk eccentrically, patients learn to use muscles properly to stabilize the spine, pelvis and shoulder blades."
Pilates training has changed not only the types of exercises she uses, but also the parts of the body on which she focuses.
"Pilates has taught me to look at the body as a whole," she said. "In the past, if I was treating a lumbar problem, I would look at the root of problem, such as a bulging disc, and work around this area. Now, I look at it more globally. I explore the reason why a patient may have a bulging disc. A lot of it comes down to abnormal mechanics, and abnormal mechanics are often caused by weak abdominal muscles, which can destabilize the spine and create pain."
Idelle Packer, PT, helps patient Tommy Millsaps with his back pain
The Alexander Technique is another approach that aims to change the way people move their entire bodies to alleviate pain in a specific area. The principles of the technique were developed in the 1890s by Frederick Matthias Alexander, a Shakespearean orator who suffered from voice loss during his performances. Physicians could not find a cause for his malady, and he discovered the technique as a way to alleviate his problems.
Idelle Packer, PT, MS, learned about the technique after she was injured in a car accident, which jeopardized her career as a professional dancer. "Little by little, I started learning how to organize my own movements to avoid nerve pain," said Packer, owner of Body Sense in Ashville, N.C.
Packer completed a three-year training program to become certified to teach the Alexander Technique, and several years later she returned to school to study physical therapy to gain the medical background she felt she needed to handle complex cases.
"The Alexander Technique taught me how to observe a patient's habitual muscular and postural movement patterns and analyze where they exhibited excess tension and compression," she said. "I teach patients to think before they move, because this awareness can help them avoid harmful positions."
Packer recalled a patient in his 50s who had suffered from chronic back pain since he had played rugby as a teen. She observed the man as he stood up from a seated position and noticed his back was slumped as he sat. As a result, his chin jutted forward as he lurched forward to stand up. When she asked him to lie down in his preferred sleeping posture, she observed his back was curled forward in the fetal position — similar to the hunch in his seated slump.
She explained to the patient how his movement patterns were putting a sustained posterior force on his discs, and she guided him into a preferred sitting position. With gentle manual cues at his neck, she asked him to release the tension in his neck, and she guided his head upward. Then she directed his knees so his thighs were moving away from the pelvis in a more neutral position, and as a result his back was not as prone to slump.
After seven sessions, the man knew how to apply the postural principles of the Alexander Technique while working at a computer, sleeping, walking and swimming. He also applied them while performing prescribed physical therapy exercises at home for back mobility and strength. With these simple adjustments in posture, his back pain decreased dramatically.
"Awareness produces change," Packer said. "Patients learn new coordination patterns that change the way they function, and this changes their structure. They are often surprised when they wake up without pain."
Although studying alternative therapies may require extra time and energy up front, Packer, Malmborg-O'Kelley and Boekmann said the benefits of the additional training are obvious when they witness progress in patients who had resigned themselves to lives of chronic back pain.
"By having both Alexander and PT training, I can assess with physical therapy criteria through an Alexander lens," Packer said. "I can teach patients the technique and then also use other modalities to help, such as electrical stimulation and the cold pack. It is remarkable to have so many tools at my disposal. I have helped many people who have seen an array of different practitioners with minimal results, and I give them hope again."
Heather Stringer is a freelance writer.
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Monday February 13, 2012