Do you suffer from low back pain? If you do, you are not alone. Millions of Americans develop low back pain at some time during their lives. The tightness, aches and pain may be due to lifting the wrong way, making sudden moves or taking a fall. Maintaining poor posture, carrying extra weight, being out of shape and living a stressful life are some causes of low back pain. While certain steps may be taken to avoid back pain through a variety of common sense approaches to daily living, medical attention for back pain is necessary, especially for the following:

1. Constant pain, tingling, numbness, or extreme weakness in your leg
2. Difficulty controlling your bowel or bladder
3. Numbness in the groin or rectal area
4. Fever and chills

General: General risk factors include age, physical fitness, weight and height. The incidences of low back pain increase with age, excess body weight, poor physical condition and during pregnancy.

Postural/Structural-Postural or structural abnormalities are associated with a high incidence of low back pain. These abnormalities can be identified by a physical examination and testing by a healthcare provider.

Occupational: The requirement for lifting in a twisted position is the strongest risk factor for future low back pain. Other occupational risk factors include constant twisting, bending, stooping, lifting extremely heavy objects, sitting, standing, and working on poor surfaces.

Environmental: Cigarette smoking is associated with low back pain. In fact, smokers have twice as much pain as nonsmokers.

Psychosocial: Stress, anxiety and depression are associated with an increased incidence of low back pain.

Recreational: Although regular exercise is generally recommended as a preventive measure by many healthcare providers for low back pain, certain high-impact activities such as running, aerobic dance and basketball may aggravate back problems.

BACK PAIN RELIEF
Relieving back pain may be your first concern. According to many healthcare providers using ice, over-the-counter medications and heat are remedies you can do at home. It is also important that you keep moving. Prolonged bed rest or sitting will actually aggravate your pain, while walking or stretching frequently help lessen the pain. However, it is advisable to check with your physician first.

1. Non-prescription medications such as aspirin, acetaminophen, ibuprofen and naproxen can help reduce pain. It is best to check with your doctor to make sure you are taking the best medication for you.
2. Ice is great for decreasing pain. Apply an ice pack at the point of pain. (Don't apply ice without an outer protective covering. If ice is not available, a bag of frozen vegetables will work). Apply for approximately 20 minutes each hour. Ice can be applied on this intermittent basis over a 24 to 48 hour period for immediate pain relief.
3. If discomfort still remains after icing for two days try heat. A heating pad or hot water bottle wrapped in a towel and applied to the sore area for approximately 15 minutes each hour can relax the affected muscles.
4. Relaxing in a warm tub or shower may also help to lessen low back pain by relaxing tense muscles. Also, stretching and massage therapy can help relieve muscle tension.
5. Maintaining good posture can help relieve discomfort. Stand tall and avoid excessive curve to low back and pelvis while maintaining a neutral spine.
6. Relax! Focus on dealing with stress and your back pain often disappears.

• Use back rests and lumbar supports when sitting.
• Make sure seats offer optimal seating comfort and support whether you are at the office, home or in a car.
• Quit smoking, but wait until your pain has decreased for better success.
• Maintain your weight by eating a healthy diet and exercising regularly.
• Reduce stress and anxiety.
• Change your position regularly. For example, if you find yourself sitting for long periods of time, try to switch between sitting and standing.
• Adjust table and work station to comfortable heights.
• Avoid activities that are clearly associated with previous episodes of pain.
• When lifting, always keep loads close to your body, face the load and use proper lifting techniques.
• Allow for adequate warm-up and cool-down before and after exercise.
• Always wear protective footwear and avoid exercising for prolonged periods of time on hard surfaces.
• Strengthen your abdominal and back muscles to help maintain good posture.
• Stretch your muscles frequently to keep them relaxed and flexible (focus on upper and lower back, and front and back of thighs).

1. Lifting: When lifting, face and get close to your object. Stand with feet shoulder-width apart bending at the hips and knees, tightening your abdominals and keeping a slight arch in your back. Take a deep breath and exhale as you lift with the muscles in your legs and buttocks. Stand tall and carry object close to your body.
2. Getting in and out of bed: When getting out of bed, roll over to your side. Using your arms, push your body up to a sitting position with your legs lowering toward the ground. Use your arms and legs to bring you to a standing position. Reverse the steps to get into bed.
3. Getting in and out of a car: When getting into a car, stand with your back turned toward the side of the seat. Using your arms and legs, lower yourself into the side of the seat then gently scoot into the center of the seat. Sitting sideways in the seat, keeping your back straight and moving as an entire unit, pivot your body around until you are sitting erect and in front of the steering wheel by bringing one leg in at a time and grasping onto the steering wheel.
4. Sitting: Sit in a chair that provides lumbar support. If not available, utilize a rolled towel or pillow. Sit with your knees level or slightly lower than your hips with feet flat on the floor. Maintain good posture from your head to your toes keeping your ears, shoulders and hips in line with each other.
5. Prolonged Standing: When standing for long periods of time it may be helpful to elevate one foot off the ground and rest it on a step stool to help relieve stress to the low back.

Note: This information was derived from various orthopedic/medical publications, including The Sports Medicine Bible, Lyle Micheli, MD; Krames Communications: Back Basics and Physical Activity and Fitness Research Digest (Healthy Low-Back Function).

In most cases, persons using prescription and over-the-counter medications according to their physicians' instructions can safely participate in well designed physical exercise programs. In fact, with regard to certain conditions, proper medication can help to make participation in physical activities safer, more productive, and, in some instances, possible. However, the side effects associated with a number of commonly used medications (and combinations of medications) can create the need to modify fitness programming in order to accommodate predictable drug/exercise interactions. Below are several widely applicable examples.

BETA-BLOCKERS
Beta-blockers are frequently used to treat hypertension, arrhythmias, angina and, in some cases, migraine headaches. Many stroke patients use beta-blockers and/or other cardiac drugs. Because diabetes dramatically increases the incidence of cardiovascular disease, beta-blockers are often prescribed for diabetics.

With regard to diabetes, hypoglycemia may be masked when both insulin and beta-blockers are in use. In order to prevent diabetic emergencies, persons with diabetes should cooperate closely with their physicians and dietitians to achieve and maintain an optimal balance among their nutritional, drug and exercise programs.

Because beta-blockers can slow exercise heart rate by as much as 20 percent or more, workout intensity parameters (training heart rate zone) should be prescribed by the physician based on appropriate assessment test results. Training heart rate must not be estimated with formulas popularly used to calculate a percentage range of the age-adjusted predicted maximum heart rate, because doing so could result in exercising at one's maximal heart rate.

Like many commonly prescribed drugs, beta-blockers can increase the risk of dizziness and light-headedness, especially when one rises from a chair-seated position (or other low posture) to a higher position. These effects may be further elevated when nitroglycerine, another cardiac drug, is taken in combination with beta-blockers. To discourage accidental falls during exercise, fitness activities should be designed to omit unnecessary or excessive up-and-down movements. When changing exercise positions, one should do so slowly and have balanced support available in the form of a helper, a sturdy chair, or some other stable object. In fact, many types of medications, particularly cardiac drugs, can significantly increase the risk of dizziness; so when purchasing a new medicine, always carefully examine all of the information provided about the drug by your pharmacist.

DIURETICS
Diuretics are used to reduce edema, or swelling, due to salt retention in disorders of the heart (such as congestive heart failure) and other organs. Often in conjunction with other drugs, diuretics may be used to treat hypertension.

Although not all types of diuretics contribute to a depletion of potassium, some may result in potassium deficiency, causing muscle cramps. Therefore, persons using diuretics should consult their physicians regarding the advisability of increasing their dietary potassium consumption (e.g., by eating a banana daily or taking a potassium supplement).

Diuretic use has been associated with lowered work capacity, making proper pacing especially important during physical exercise activity.

Significantly, another potential side effect of diuretic use is dehydration. Consequently, adequate fluid intake is necessary before, during and after physical exertion. (Note: This characteristic is also shared by the cardiac drugs, beta-blockers and ACE-inhibitors.)

ANTICOAGULANTS
Anticoagulants, commonly referred to as "blood thinners," help to prevent the clotting of blood and are often used as a part of the treatment plan for conditions in which clot formation is dangerous (e.g., heart attack or cases in which blood clots have developed in the limbs). Aspirin is sometimes prescribed as an anticoagulant.

Anticoagulants raise the risk for bruising and hard-to-control bleeding, both internally and externally. For this reason, persons on anticoagulants should choose their recreational and exercise activities wisely, avoiding high-risk physical sports that pose a significant probability for injury.

CONCLUSION
While only a small selected sample of the many types of medications available on today's market are addressed above, they represent the special concerns which should be acknowledged in reference to combining exercise with drug therapy.

It is important to note that special populations may have heightened sensitivity to a drug's effects and side effects. For example, many older adults are on multiple drug regimens that can contribute to complications and interactions. Due to reduced kidney function, drugs may not clear the elderly person's system normally (being excreted rather slowly from the body). Physical changes brought on by age or disease can make seniors three times more likely than young persons to experience adverse drug side effects, such as dizziness, blurred vision, and nausea—all of which must be taken into account for sound exercise programming.

Regarding exercise and medications, major recommended guidelines include:

1. seeking competent medical guidance concerning the use of both prescription and nonprescription drugs
2. discussing with one's physician the drug's potential interactions with exercise and with other lifestyle elements, such as diet and additional medications
3. following medical advice with regard to using the drug
4. taking a proactive approach in terms of educating oneself regarding the effects and possible side effects of any drug(s) in use
5. adjusting one's exercise activities accordingly.

Diabetes mellitus affects approximately 16 million people in the United States, but an estimated 10 million cases have not been clinically diagnosed. It is the fifth leading cause of death and is a chronic disease without a cure. Despite an enormous amount of research, there is still no clear understanding as to the cause of diabetes, however, genetics and environmental factors such as obesity and lack of exercise appear to play major roles.

There are two types of diabetes, both involve malfunctions of the body where it does not produce or properly use insulin. Insulin is the hormone (secreted by the pancreas) that converts sugar, starches and other food into glucose, which is the fuel the body needs for energy.

Type 1: An auto-immune disorder in which the body produces little or no insulin. It most often occurs in children around the age of puberty but may also occur in young adults. Someone with Type 1 diabetes must take daily insulin injections for the rest of their lives but this type only accounts for 5 to 10 percent of diabetics.

Type 2: A metabolic disorder where the pancreas can produce insulin, however, the secretion levels may be too low and/or there is a lack of sensitivity of the insulin receptor cells to receive insulin leading to elevated blood glucose levels (i.e.,hyperglycemia). Symptoms of hyperglycemia are increased urination, thirst, hunger, blurred vision, nausea, dry skin, and unusual fatigue. Due to our aging population and a greater prevalence of obesity and sedentary lifestyles, Type 2 diabetes is nearing epidemic proportions.

Maintaining a normal level of blood sugar is critical for persons with diabetes. Normal blood glucose levels are 70-150 mg/dL. Hyperglycemia (high blood sugar) occurs when the glucose level exceeds 120 mg/dL before meals or 180 mg/dL after meals. Hypoglycemia (low blood sugar) occurs when glucose levels are less than 60 mg/dL.

Many factors may contribute to the development of diabetes.

• obesity: 80% of diabetics are overweight
• heredity
• age: higher incidence over age 40
• diet
• stress
• physical inactivity

CONTROLLING DIABETES
Diet: Persons with diabetes should eat plenty of whole grains, vegetables and fruits that are naturally low in fat and cholesterol. Foods high in sugar and salt should be eaten in moderation. It is important it eat a well-balanced meal about three hours prior to intense exercise or competition. The best way for a diabetic to maintain a stable glucose level in the blood is to eat several small, well-balanced meals each day.

Exercise: Regular exercise is the most overlooked and crucial treatment for controlling diabetes. Each person should engage in a form of exercise recommended by his or her physician. The intensity and duration of exercise will determine the levels of blood glucose and insulin usage within the body. Walking briskly for 20 minutes three times per week can reduce the risk of Type 2 diabetes. Your physician can help guide you on medication needed and adequate dietary requirements to assure your safety during exercise. Exercise improves blood glucose control, reduces cardiovascular risk, improves circulation and can keep you fit.

For insulin dependent diabetics, there are many factors influencing the body's utilization of insulin. Exercise may cause hypoglycemia or hyperglycemia due to an increase in metabolic demands. Among the unique considerations for the diabetic person to observe is the prevention of hypoglycemia caused by increased metabolism of foods while exercising. The following are preventive tips for persons with diabetes who exercise.

• Avoid injecting insulin into a part of the body which will be exerted during exercise. This may increase or shorten duration of insulin reaction.
• Avoid exercising at the peak of insulin activity. Injection of insulin should be administered one hour prior to the start of exercise.
• Avoid alcohol and beta-blocker drugs around the time of exercise, because they both promote hypoglycemia.
• Eat a snack just before and during exercise.
• Keep simple carbohydrates (fruit juice, hard candy) and other food available. If you are a competitor, ask the team physician to carry extra insulin for emergencies.
• Always carry emergency cash and identification listing your medical condition and medications used.
• If you experience pain in your chest, nausea, heart palpitations or severe shortness of breath during exercise, stop and consult your doctor.
• Test blood glucose before, during or after exercise.
• Watch for post-exercise hypoglycemia up to 15 hours after exercise. Symptoms are increased sweating, excessive hunger, rapic heart rate, headache, impaired concentration, confusion and drowsiness.
• If blood glucose levels are above 240 mg/dL, or below 60 mg/dL, don't exercise.

Aerobic Exercise: Exercise at 55 to 90 percent of your maximum heart rate three to five times per week for a minimum of 20 minutes. Check with your doctor for your specific heart rate intensity and duration.

Strength Training: Begin training at 40 to 60 percent of one maximum repetition (1 RM), gradually building to 80 percent of 1 RM. Perform a minimum of one set of eight to twelve repetitions two times per week. Make sure that all major muscle groups are worked. Approximately eight to ten exercises for a total body workout. Check with your doctor for any contraindications regarding resistance training.

Foot Care: Since diabetes is the major cause of nontraumatic amputation, proper foot care is important, especially if a diabetic is exercising, which leads to sweaty feet and can precipitate foot problems. The following are tips to prevent foot infections.

• Wash your feet daily.
• Use foot creams or lubricating oils.
• Have a podiatrist show you how to cut toenails correctly.
• Never cut callouses or corns.
• Never walk barefoot.
• Wear appropriate shoes.
• Inspect the inside of your shoes daily.
• Seek medical care for all skin lesions.
• Avoid smoking and the use of all tobacco products.

BEHAVIORAL CHANGES
Anxiety, depression and denial are extremely common in diabetics and are often treated with prescription medications. These medications frequently have side effects that can diminish the diabetic's capacity to complete a proper exercise routine. Recognizing the differences between side effects which do or do not affect a person's exercise participation is crucial to the value of the exercise itself.
Note: This information is for educational purposes only. As such, it is no substitute for medical advice. Always consult your doctor. Shinsplints is a catch-all term for any pain between the knee and ankle that occurs in runners or other athletes engaged in running/jumping-type repetitions. Specifically, it is a pain along the inner or outer front surface of the tibial shaft (shinbone) and should not be used to describe all lower leg pain.

Use this card systematically to help find the underlying cause and identify the correct diagnosis. Follow the recommendations listed. If little or no relief is obtained, often a combination of types could be the problem.

THREE COMMON TYPES

1. Stress Reaction and/or Fracture (crack in the bone)
   Look for: Slight swelling and tenderness directly over the large bone in the front of the lower leg (tibia). Tenderness may also occur in the fibula just above the outer ankle, especially as a result of aerobic dance exercise. Pain can occur while running, after running, or even when standing.
   Cause: Too much shock to the leg, either due to extrinsic factors:
   • hard surfaces
   • worn or stiff shoes
   • too much, too soon
   or intrinsic factors:
   • inflexible or weak shock absorbers (muscles and ligaments)
   • overuse of the bones before they have time to strengthen

   Recommendations from the...
   Coach: With early tenderness, decrease intensity of activity. With severe pain, stop all activity until healing occurs. Try alternate activities (bicycling, swimming), run on softer surfaces with multi-layered shoes, rotate shoes or buy new shoes.

   Doctor: Determine excesses or inadequacies in stretch, range of motion or strength. Begin a remedial program immediately. If fracture is suspected, obtain an X-ray or bone scan. Rest until healing occurs. In some cases a cast may be necessary.

2. Posterior Tibial (and sometimes Anterior Tibial) Muscle Pain
   Look for: Pain, tenderness and subtle swelling over the muscles in the lower third of the leg, either during or directly after activity.
   Cause:
   • overuse
   • excessive tightness of the calf
   • excessive pronation of the foot (flattening and/or tilting toward instep, placing strain on the tibial muscle and its tendon)
   Recommendations from the...
   Coach: Stop exercising until pain is relieved for at least one week. Gradually resume, but only at half your previous exercise time. If running, run on soft, level surfaces with properly cushioned shoes. Increase your Achilles stretching time to one full minute?no bouncing. Use an ice pack after activity.

   Doctor: Educate yourself about overuse syndrome. Break the cycle of inflammation, pain and fibrosis by applying ice after exercise. Elevate the leg to decrease swelling. Then rest until the pain is gone. Try alternate activities. Rule out foot deformities and consider shoe corrections if necessary. Non-steroidal anti-inflammatories can be prescribed.

   Aerobics Instructor: Wear leg warmers to help keep muscles warm. Warm up shin area by performing 10 minutes of ankle circles and toe taps before activity. Perform toe strengthening exercises on a regular basis (e.g., picking up marbles).

   Foot Doctor: Stabilize the heel and keep the foot from pronating. Have an in-shoe orthotic device fitted, giving support to the arch to reduce work by the posterior tibial muscle.

3. Compartment Syndrome
   Look for: Pain in the muscle belly in the outside front of the shin. Pain on walking, especially when rising up on toes, which doesn't go away with rest. At later stage, numbness develops or even paralysis, presenting a medical emergency.

   Cause: Overuse leads to tissue breakdown and swelling, causing a constricted blood flow in a closed compartment of the leg. Muscles in the anterior compartment area can be comparatively weaker than the calf muscles. This imbalance causes antagonistic contracture and pain.

   Recommendations from the...

   Coach: Prevention is the answer. Don't press beyond the limits of pain. Strengthen the anterior compartment muscles by pulling weighted toes up toward the knee. Include more stretching and flexibility exercises for the calf muscle. Avoid hills. Exercise on level surfaces with shoes that provide good support.

   Doctor: If severe pain persists with rest, numbness in the web between the first and second toes can exist. This constitutes a medical emergency. Seek immediate treatment. Surgery is often indicated.

   Aerobics Instructor: Avoid too much, too soon. Adequately stretch calves before and after activity, with both plantar and dorsi flexion. Strengthen dorsi flexors to avoid imbalances.

If you don't know which condition you have...

SIMPLY REMEMBER:
If the pain is mild... choose a different aerobic activity, such as swimming, bicycling or aerobic dancing. These are all activities that will maintain the muscular strength and cardiovascular endurance you have already achieved as your shinsplints heal.

If the pain is moderate... rest the leg, elevate it and massage with ice after exercise. If the pain continues, seek medical advice. If it hurts to walk, rest it for a few days.

If the pain is severe... stop all exercise and seek medical advice from an appropriate medical specialist.

We hope they never happen to us, but emergencies do happen and sometimes they do happen to us. The following nine situations represent just a few of the many varieties of emergencies that can and do arise daily. Clearly, this simplified card is not designed to take the place of a proper course in first-aid or cardiopulmonary resuscitation (CPR). However, this overview of common emergencies may help you accurately diagnose a potential emergency and make the difference between life and death.

• Post accurate telephone numbers for all available emergency assistance (e.g., 911).
• Keep a comprehensive first-aid kit stocked.
• Assign individual responsibilities for an emergency situation.
• Become certified in CPR and basic first aid.