 Good afternoon everyone. So a common question that is posed to me when people come to consult me for spine surgery is what are the exercises that I need to do? Do I really need to do any exercises when I have back pain? Can I do exercises when I have back pain? And what are those exercises which is safe, which is unsafe? There are lots of myths and misinformation among the general public. The moment the patient leaves my consultation room, he has a barrage of information. His attenders give him advice, his neighbors, his friends, his mother, his or her extended family. Everybody has something or the other to say. Either it is telling them use pillows when you sleep or sleep without pillows, don't sleep on your back, sleep face down, don't sleep on a mattress, sleep on the floor and so on. So the same goes with even exercises. People say do yoga. Some people say don't do yoga. People say don't do deadlifts while you can actually do certain kind of weight training exercises. People don't know about Plants and Pilates. So those are all the unsolicited advice as well as uncertified advice that is being given to patients who need actually a professional approach and a professional opinion on what are the exercises that they should be doing. So I thought why don't we just talk about something very simple as exercises even though most of our practice is about spine surgery but 90% of patients who come, 95% of patients who come to my clinic actually go back with the advice that they should do more exercise. So here we go. Let me share my thoughts today with this presentation. So 80% of people go through back pain at some point in their life and that's a fact. I myself have had back pain many times and I have treated it with exercise, back strengthening, proper posture and at times with medications. So there's nobody according to me who spares back pain. That's primarily because we are, we stand on two feet. We don't, we are like all other animals on this planet. We don't stand on four legs. We are not quadrupled. We are bipedal. So a lot of the focus, the loading happens on the mid-back region and that's why we tend to have back pain. So it is the fifth most common cause for physician visits. According to approximately 2.6% of all physician visits about one quarter of the US adults report low back pain lasting at least a whole day in the last three months. These are all the data that have been collected. 6% of US adults randomly surveyed by telephone have at least one occurrence of severe acute low back pain during the one year period. 39% of those seeking medical care for their episodes and it's quite a disabling problem. Low back pain is one of the most chronic, most common cause of chronic or permanent impairment in adults above the age of 65 and the most common cause of activity limitation in people above the age of 45. Between 2 to 8% of US workforce is disabled or compensated for back pain injuries every year and approximately five percent of people with back pain disability are thought to account for 75% of the cost associated with back pain. So meaning to say that it's quite an expensive reposition and if the solution can be a simple change in lifestyle with back strengthening exercises then so be it. Why is back pain so common? The human spine is stressed even while we sit. Most of the time we don't maintain a proper posture no matter how much of exercise you do if you hold your spine your back in a wrong position for a long duration it is going to pain no matter how strong you make your spine so your posture becomes very important. We abuse our backs during our day-to-day activities every activity that we do every moment we are stressing the spine at the lumber level at the lower level may be doing household chores or sporting activities or leisure activities anything can lead to can lead to stress on the back and we are not servicing our back if you are not exercising we are not we are it's equal to not servicing it unless you service your back you cannot take care of your spine. So fundamentally to understand what how we should go about taking care of our spine let's study a little bit of the anatomy of the spine it's pretty simple it's nothing complicated it's like our teeth there are 32 teeth there are 33 spinal bones so that's divided into cervical which is the uppermost part thoracic and lumbar and lower most is the sacrum with the coccyx as you can see here the alignment of the spine has changed over many millennia so from primates to humans you can see that the alignment where the head was way ahead of the pelvis in the primate stage gradually comes and sits right on top vertically over the that is a balanced spine and even in any individual when we are in fetal form the spine is c-shaped and gradually once we develop once we learn to lift our head up we develop the cervical lordosis what we say and as we stand up we develop the curve of the lower back also and that is how we have a cervical lordosis a thoracic forward bending or kyphosis which is of a normal level and a lumbar lordosis where there is again an inward curving of the spine and and the sacrum that is the lower most part so a perfect spine when you see has to be appearing straight when you look at it from the front and when we look at the person from the back from the side the head and the pelvis have to be in the same line that is a balanced spine and the curve of the spine has to be smooth like what you are seeing here on the screen yeah so that that is a perfect spine but not everybody's spine is perfect but it need not be abnormal small variations are acceptable it's not the hard and fast tool that it has to be absolutely perfect we go by certain numbers certain degrees but we don't hold it to that in entirety so why is it so common the human spine is unique highly advanced functional unit which is designed not only to take loads but also to permit movement so here is a problem the spine has to bear weight of our body it's got nerves inside the spine so then it has to protect those nerves otherwise small impacts can cause damage it is not compatible with existence so the nerves have to be surrounded by the bone and also there are muscle attachments to the spine which without which we cannot propel our body forward effectively so if you see here in this image there are you see the bones and you can see the nerves the yellow thing there that's the nerve root and between two bones you have the disc which is a soft cushiony material and these are the nerves here so the disc is what you see between the two bones it's multi-laminar it's got many layers to it and in the center it's got something very soft like a crab meat like material now that is the cushioning shock absorber so that the vertical force the compressive force that falls on the spine gets dissipated and equally distributed in the back you see between two bones you have this joint which is the facet joint and that joint the presence of these facet joints as well as the disc allows for movement of the spine but at the same time in a very controlled manner it's not like the shoulder joint which gives you unlimited movement each motion segment that is two bones adjacent spinal bones allow for about five to ten degrees of movement collectively they have to be orchestrated to affect your movement of our body so the muscles of the the muscles of the posterior lumbar spine are what we call as the dynamic supporters there are superficial layers like the latissimus dorsi now that's a common muscle which every person who does a little bit of exercise knows the lats which are the wing muscles there are the deeper muscles like the erector spine serratus posterior and there are the very deep muscles also all these muscles need to be taken care of it's not very complicated everybody who has the the information as to how to do spine exercises are all out there and it can be easily done there are so many youtube videos on how you strengthen those muscles but people just need some kind of an assurance as to which are the right exercises and what type need to be done so how much can the spine take the spine can take a lot of load it's not a very delicate structure that you can't jump you can't twist you can't swim or you have to be absolutely careful you can't lift loads no literature has made the spine very quite efficient and extremely strong and resilient too so if you see as the load increases it can take a lot of load and then it goes into a phase of deformation and elastic phase where the bone starts stretching the ligament starts stretching and after a particular point it starts failing and that is the failure zone we have to make sure that whatever load we carry whatever exercise we do we keep those exercises at a point in the neutral zone that is from a to b here that is the neutral zone or at most it can go from b to somewhere half way to c where it is slightly elastic zone where there is excess load but that is the zone where the bone gets stimulated to become stronger and the muscles also build so a little bit of pushing the limits may be necessary to make stronger muscles so the failure strength of the spinal ligaments are also have also been analyzed and you see from these charts that the neck has very little has the least amount of strength so one has to be very careful when doing massages of the cervical spine the ligaments are much stronger in the thoracic and most strong in the lumbar spine so one has to be very careful about manipulation of the cervical spine people go for massages like Ayurvedic massages or any kind of chiropractic treatment or from local to local bone setters where they do some kind of a twisting of the neck one has to be very of these kind of maneuvers and I strongly suggest that people do not go for native treatment management of cervical spine only professional certified people in Ayurveda or any alternative therapy if they are professionally trained and that is alright but never go for manipulation of the neck so this is the motion segment again as you twist and load the spine you can see that the disc the part between two bones it starts bulging so and the nerves are here at the back so if the disc bulges towards the back then it can lead to back pain and lead to pain shooting down the leg the movement also if you see the maximum movement happens in the cervical spine this is the neck part the cervical spine in the thoracic spine where the chest wall is the movement is the least whether it is flexion extension lateral flexion or rotation of the spine and in the lumbar spine the movement is also significant but the maximum amount of rotation happens in the neck obviously our body is like a periscope you need flexibility for us to see and move around and even flexion extension because we need to look at the ground as well as look at the sky so the cervical spine has very good range of movement and the joints and the disc are designed that way that it allows for more movement so when you look at the spine in an x-ray or an MRI it's it's quite different if you see here an x-ray shows you only the bones but the discs are not visible the nerve roots are not visible and MRI scan gives us a much better idea about the disc as well as the nerves as well as the joints and what is happening with the bone so if at all anybody has chronic back ache and or excruciating leg pain originating from the back it's better to get an MRI scan and make sure that your spine is all right before you embark on any kind of a rigorous spine exercise like activities the type of back pains one has to be aware before going into back exercise and that is one is osteogenic back ache where there can be disorders of the bone discogenic back ache where the disc can get degenerated and lead to herniation what we commonly call as a slip disc spondylogenic that is from the joints of the spine what we hear as arthritis of the joints of the spine like how you develop one can develop arthritis of the knee or osteoarthritis of the knee similarly people can have osteoarthritis of the spine also myogenic or muscle related or many times people can have back pain purely and neck pain purely because of mental stress so as part of my assessment of a patient I always look at their anxiety levels if a person is very anxious then one has to address that anxiety component otherwise their back pain and neck pain will never go away so people may see one may feel that one has a major problem but it may just be major amplification of a minor problem purely by virtue of being very anxious yeah there's also viscerogenic where it can come from other organs sometimes people may have aneurysms in the aorta or renal stones which can also present as back ache or urinary tract infections which can present as back ache so the the ones which are because of the bones which we commonly deal with are that of osteoporosis where there are weak bones infections mostly like tuberculosis there can be tumors in the spine and there can be breakages in the bone because of chronic overuse now all these one has to be aware of the reason for speaking about this is that one should be aware that if you're having these kind of diagnosis then you should one should not be undertaking rigorous spine exercises without consulting a professional first get a proper professional opinion and only then set out on doing your spinal exercises and muscle building there are where causes as I described viscerogenic vascular or psychogenic and many a times you get a good result when people have with surgery when people have sleep fear it's got lumbar canal stenosis infections tumors deformities of the spine whereas poor surgical results are noted in patients who have back pain which are which do not have all those problems like lumbar canal lumbar spondylosis or postural back ache or because of osteoporosis now or like vitamin D deficiency severe vitamin D deficiency leading to osteomalacia now even all those disorders don't improve much with surgery and one has to treat them with treat the primary cause like treat the deficiencies and then work on strengthening the back muscles so coming down to what are the effective exercises for the spine all kinds of exercises are okay like a gym workout isometric workouts isotonic workouts plank exercises yoga pilates and aerobics so a whole range of them so one of the common statements that I make to every patient of mine is do all the spine exercises which are meant to be done or not horizontal position not the one which has done in a vertical position where one is bending forward and trying to touch the toes or doing positions like surya namaskarans if you have already have an existing problem like if your post surgery if you have undergone a slip disc surgery where the disc has been removed or you had a fracture where fixation has been done with screws and rods or if if you have a tumor where part of the spine bone has been removed and reconstructed in such situations one should be careful about what of do a theory of doing exercises like surya namaskara at a very early stage once the spine is strong enough then one can definitely embark on even surya namaskara or doing burpees or doing jumping jacks and all those exercises which which can be very beneficial but there is a time for all of these these exercises so what I have done is kept it very simple that the most important thing more important than just focusing on a specific muscle of your spine general condition is of utmost importance I would say it is more important than just focusing on your back muscles or your abdomen muscles so general conditioning three of the commonest ones out of which walking is the easiest if you anybody can do it anywhere I would recommend walking for four to five kilometers in 40 to 50 minutes every day at least six days a week now what happens with walking or cycling or swimming is that in one it it helps you in improving the vascularity of your muscles to it improves your exercise tolerance and your cardiac function three because of the because of optimized conditioning you can even tolerate pain better four with general body conditioning your balance improves so that you you don't you can you can maintain yourself in good posture even in tricky situations so that you don't have unnecessary faults so all these benefits are there with doing general body conditioning exercises cycling I would recommend for about 30 minutes continuous cycling every day if not walking ideally it would be very good to to walk for 10 minutes cycle for another 10 minutes and swim for about 20 minutes and that would really you know cover all the muscles of the body so coming to the the most basic of exercises what we call as an elbow plank now that is an excellent exercise for for building your core muscles as you can see here it's not only the back muscles which are kept taught but even the abdomen muscles the gluteal muscles the the leg muscles your arms are all taught even the neck muscles get exercise with the plank this is an isometric exercise that is you are maintaining the tone you are maintaining the length of the muscle but increasing the tone of the muscle so by keep putting it into contraction for a prolonged duration of time now this gives overall muscle strengthening and it's invaluable I would say the whole it's more important to have a good trunk and core muscle strength than to have better biceps yes biceps helps you in getting work done around the house but core muscles are what keeps you upright helps you maintain good posture helps you in walking trekking and doing all kinds of outdoor physical activities it helps you in moving geriat in the geriatric population it helps in moving oneself from lying down to sitting position sitting to a standing position every movement depends on our core muscle strength and if we ignore our core muscle strength then we will find it very difficult to do our day-to-day functioning so a plank exercise is an excellent way of working out for anybody it does not cause any harm you're not moving the spine you're only tightening the muscles around the spine even both surgically a patient can just as he's lying down he just when he wakes up in the morning he can just go on his belly go on the elbow and like on the bed itself on which he's been sleeping hold that position for 30 seconds do it in different in 30 30 30 maybe about 10 times you would have covered like five minutes of plank and gradually increase the time duration of the plank exercise so if you can do hold a plank for the elbow plank position for say one to two minutes that's very good and if you if you work on it and finally do a plank session of about 10 minutes that's like really awesome so and it's very simple it's not damaging it won't hurt your joints it will not move the disc if you're worried about the disc popping up again after the surgery it won't lead to any such situation it's a natural position you're just lifting yourself up from the or from your mattress that's all it's like I have not seen a more effective exercise than a plank position an elbow plank position so I would strongly recommend that to most all patients actually yeah so the second important good exercise that can be done is to do your regular push-ups now push-up exercise once you graduate from a plank position where your whole strength has increased has improved you can go on to making it a little dynamic so once you can do about 10 minutes of plank in different batches then you go for push-ups that would further increase your upper body strength as well as your back because to hold your pelvis up while you're doing your push-up exercises needs to needs a toning up of the muscles and that's exactly what happens to the paraspinal muscles so push-ups everybody knows you have to learn how to do the right push-ups a word of caution here that if there is any exercise which worsens your pain or gives you a sharp kind of pain then you must give up that exercise for the time being till your condition improves your body is trying to tell you something so one shouldn't be stubborn and say no if I have to do my if I decided on 10 reps of push-ups and if you have a sharp kind of pain at five then you this you shouldn't be too stubborn your body is trying to tell you something so go on to something easier like a plank which is equally effective the third simple exercise that we advocate to all is that of extending the spine like how you can see over there you start with the prone position lying face down and you can do it in the morning when you wake up from bed before you get out of bed you can finish this workout like you just go on your elbow push yourself up and push it as posteriorly as possible so that your entire back from starting from the neck upper back lower back as well as the glutes and hamstrings get get taught here now one of the concepts for muscle strengthening in any part of the body is a mind muscle connection that is even a simple exercise when you're doing a simple exercise you should think of those muscles and you should mentally strain those muscles when you do when you get this mind muscle connection that's when your muscle actually strains a little more and develops further this is scientifically established and most people who work out on strength in the muscle so mind muscle connection is very important another exercise is when you do when you when you're in a quadruped position that is knee and knee and palm are in contact with the ground and then you lift say the left hand a left upper limb and the right lower limb so this is another exercise which is very simple the idea is not to do it very fast but to do to hold this position for as long as you want what I recommend is you hold this position for about 10 to 15 seconds and then switch over to the opposite side so it's like a cross body extension if it's the left upper limb then the left lower limb goes up this is excellent for the core muscles of the back as well as glutes hamstrings as well as the abdomen so as I said think about the muscle and do the exercise every every exercise that I'm describing is something which is done very slowly there's nothing that is done in a very bouncy manner or in a rapid fashion every exercise is done in a controlled manner so that there is no disturbance to your balance or equilibrium but equally effective as doing any kind of weight training or heavy running one doesn't need to really run to get strong back muscles one needs to do controlled purposeful movements for muscle building having said that at this point let me add that it's good it's necessary to have good nutrition nutritious intake protein intake has to be optimized any person trying to strengthen his muscles or good health of and of a health of his spine needs to be taking proper having proper protein intake be aware of your nutrition make sure that you get about 0.8 to 1 gram of protein per kg of body weight that is if you're 70 kilos try and get 70 grams of protein into you that and now it's pretty easy to calculate the way what you eat put it in an app and see the amount of protein that that you need to be that you're actually getting out of that particular food product this is the I see that somebody has raised their hand but I'll answer that question in the head once I'm almost coming towards the end of my presentation in another five minutes and then we can freely discuss so this is another exercise which is a bridge exercise as you can see you can lift your be on your keep your foot planted firmly on the ground and shoulder on the ground and lift your pelvis up similarly you can do a next extreme kind of a next level of exercise not extreme but the next level of exercise where you keep your foot on a bench and lift the pelvis up if you're a more fit person you can engage in this kind of an exercise activity the next level of exercise is that of lifting both your hands and legs up while lying only on the elbow or on the belly and pelvis with the face down so this is again a very effective exercise instead of doing it on the floor you can use a swiss ball and which is very convenient soft more user friendly and you don't need to really be on the ground to do these exercises you can ease yourself on to a swiss ball and get down to doing back exercises if you're in a gym and you have an apparatus which helps you in maintaining a position where you can be obliquely positioned and bend forward and lift yourself up as depicted in this exercise in this picture in front of you that is a very effective way of doing slow controlled put mind to muscle connect the two feel the muscle contracting repeat at least 10 times in every set you can do up to 30 40 50 repetitions in the morning 50 in the evening these are very controlled to minimum damage you just need to be sure that you do it in a slow controlled manner you can use some weights and do these simple exercises and if you have a spine problem I would advise you not to use weights if you want to use weights use very low weights one or two kilos but and do them properly here leaning forward and lifting the weights away from the body sideways will help you in building the muscles around the wing muscles in the upper back the wing bone scapula which is at the upper back the muscles around to get strengthened with this and this exercise is to strengthen your lats the wing the the wings on the side yeah so a lot of talk about yoga yes I for people who have spine problems which like sleep days or infections or tumors of the spine definitely don't do a standing and bending forward kind of exercise but these horizontal exercises which have been described centuries ago in yoga has is very very effective and very useful I recommend all these exercises for my patients as long as it's done in a slow and controlled manner and that basically is the essence of of yoga so a lot of cat camel stretches glute bridges or swimming pose or the child pose all of them are good for flexibility as well as strengthening and maintaining good posture of the spine so exercise low stress aerobic exercise in a controlled manner can prevent delivery debilitation due to inactivity during the first month of symptoms and this can be started in the first two weeks after onset of acute low back pain conditioning exercises for trunk muscles are helpful with patients who have acute problem particularly if symptoms persist but may aggravate symptoms more than aerobic exercise in the first two months there is no evidence to say that back specific machines any high-tech machines provide benefit over the traditional exercises this is a very important point it's not that you need to buy something and apply to you as an exercise form for you to get good spine help no you can do it without any equipment it's just the posture that you maintain and the way you do the way you contract the muscles in a controlled manner the guidelines suggest that there is gradually increasing exercise quota results in better outcomes than telling people to stop exercise while if pain occurs meaning to say they're not saying that if there's a sharp pain you continue exercising what they say is that if there is mild pain please do a little bit of exercise and gradually increase it as the pain is gone there are other guidelines that recommend that supervised exercises as a first line of treatment for chronic back pain is what is recommended they say that there is no recommendation of a specific kind of exercise it's not that you have to do yoga or you have to do planks there are exercises which you are familiar with which you can manage to do which you can do there is no one way of doing exercise thank you very much i i hope all of you benefited from this small presentation which i felt was necessary in term for spine health i'm i'll be looking at the question any questions yeah hi sir is one question from Mahatesh Kanabur that is is cycling good or bad for back pain now that's a very good question cycling is one of the safest and best ways of exercising and body conditioning it's very good for the back what i suggest is to use stationary cycle where you're just sitting with forces of external influences are not disturbing your cycling so i would recommend cycling in the gym in an exercise cycle so that you can increase the grade of the level of resistance that is there and that can be very good for even spine because you have to do it sitting vertically next question i do regular exercise and still get don't get to see any improvement on low back pain what should be the next step so yeah if the pain doesn't improve then we have to find what the pain generator is is it coming from the muscle is it from a facet joint is it coming from the bone we'll have to look into all that is there a small spondylolisis or break in the spine which which could be leading to the pain so we need an x-ray evaluation and mi evaluation if required or if we feel that it is metabolic then we'll have to look at vitamin D levels or look for other metabolic profiles rheumatoid arthritis is immune system related problems but then if it is a small niggle then it's most probably muscular there may be some fibiotic bands or some old injury which has happened which is just failing to heal maybe a few days of rest and some anti-inflammatory medications should help you can you please suggest any neck exercises yeah that's a good point now planks actually help in even strengthen the neck but for neck interestingly i do not recommend that people move their neck like rotation activity of the neck i don't recommend that because many of them have many of my patients have uh tight spinal canals where there's very less space for the nerves and in such situations or too much of rotation and manipulation of the neck can lead to weakness in the hands and legs so what i suggest is isometric exercises i will since i've not shown it in my presentation i'll demonstrate it to you all you have to do is make the entire exercise is done in a neutral position where your head is in head and neck are in neutral position offer resistance and push your head forward with the resistance from the hand hold it there for five seconds and then relax for five seconds and then repeat it again do it 25 times every day if possible 25 times in the morning in 25 times in the evening uh second exercise is to do the same thing pushing backwards holding there for five seconds and relax for five seconds repeat it 25 times similarly sideways push offer resistance hold for five seconds and relax for five seconds and then the opposite side again five seconds hold and release and also take weights in your hand depending on your ability three four five kilos lift it up and down do it 25 times every day yeah and so now we're talking about the neck i would suggest that you maintain good posture of the neck make sure that you're not having a poking chin posture always tuck your chin back keep your chin tucked inside don't keep it this way don't let your shoulders droop down make sure that you use arm rest arm support sit back this way then you dry make sure that your head rest and the head are in contact there are two benefits of that and that is one is if you there is a sudden jerk your head doesn't go forward and then go backwards completely that can be damaging to the spine there are catastrophic events that have happened because of that simple problem and the second is that it gives some support for the neck muscles on a long drive uh next exercise can we see back pain traversing to the leg at times is it a serious problem by s s shedding okay so that's whenever a whenever a patient has pain which is shooting down the leg it means that there is a compression of the nerve in the spine and usually in a young person it's a slip disc where there is a disc which has bulged out and is squeezing the nerve and that need that 99% of the time it's not a serious problem but it needs to be attended to it's not something to be neglected there are medications for it and a little bit of rest and correction of certain postures and then you should be fine if a person has pain shooting down the leg along with weakness in the foot and numbness and difficulty in passing urine now controlling urine now that's a serious problem that needs an emergency surgery in the elderly when there is pain going down the leg it could be because of wear and tear of the joints or it could be any of the many problems that can happen in the spine so anybody who's above the age of 50-55 needs to be needs to visit a consultant specialist as early as possible not that you need to panic but it's better to at least screen the spine with an x-ray and make sure that it's not nothing more than just a usual simple slip disc there was if I have back pain what should I do to reduce it yeah so that's a good question by Rajneesh now if you have back pain there could be many causes we'll have to identify what the cause is before we say that it's just muscular pain there are many things and a specialist can do it without doing any investigations there are ways in which a spine specialist would understand your problem without doing MRIs or blood tests or and do only those necessary tests so the consultant specialist and and then find out what the pain generator is and based on that treat treat the problem it could be treated with exercises or with some medications or with some sometimes even physiotherapy yes Kamita says what us what high doctor what exercise or treatment you suggest for pain in the tailbone and pain also passes to the left ankle when seated for two hours yeah so tailbone is what we call as coxidinia because the tailbone or the coccyx is the lowest part of the spine and that can get damaged fractured because it is a free it's not connected to anything else it's sitting freely projecting down from the sacrum it can crack because of a sudden fall usually they people come after falling from the stairs you know bumping down the stairs but at times I've seen people have these kind of cracks even when they have had sudden loss of weight and they lose the mass muscle mass over the gluteal areas they also have more pressure falling on directly on the bone and it can crack or people who have osteoporosis weak bones can fracture it spontaneously with small impacts like a bump or during while going on a two wheeler also and that settles down by itself when there are tail there is tailbone pain if it doesn't settle down then we do give some steroid injections around this around the coccyx and that should help in very extreme cases there we even operate on the coccyx and we remove the coccyx if it is too painful in some individuals who can even sit because of because of the pain in the tailbone. So next question Mr. Muthukrishna says there is saying that bone friction happens when we grow older is that true that's the first time I'm hearing the word bone friction if you mean bone fracture if it's a typo error yes more fractures of the bone happen with osteoporosis which happens with aging if you mean by friction wear and tear of the joint yes if you mean wear and tear of the joint then that that can happen with aging and it's not decided by the kind of activity that we do on what we eat it is purely a predisposition of an individual genetically to early wear and tear so that that's a very common question that people ask me doctor why has this joint of my bone out it has not happened to my mother or it's not happened to my friends who are much older to me but why has this disc gone out why has the joint gone out what we do know is that there is a certain amount of genetic predisposition to this our body's programmed that way that some people may have wear and tear of their knee joints or their spine early but they may never develop a cataract whereas some others may develop a cataract at a at the age of 40 while they don't have even one gray hair on their scalp till they are 70 so different parts of our body wear at different places next question is there any good exercise for fat burn now I think I'll stay away from that question from Anup there are a lot of I mean I think we'll stick to the back pain topic any suggestions to for people sitting in office for long hours yeah always maintain proper posture sit use a back support don't sit sit on a chair which has a back support keep a small rolled pillow or a sheet a cloth towel behind your lower back so that the curve of the back is maintained um if you're sitting for long hours make sure you get up from your seat at least every half an hour or 45 minutes walk around and and and then come back do your back strengthening exercises the ones which were demonstrated it's very easy you don't need space to run you just need three by six feet area and some privacy and you can do your back strengthening exercises doing two or five minutes of back strengthening every three four hours if you're having a very you know monotonous working day you can break that monotony with some back exercise and really help you big time uh next question by Dr. Maya Masquinas these days all are sitting down because of online classes young children how can they prevent posture issues yeah so uh that's that's a good question usually children are very resilient to pain i'm a alarm bell is ringing in my mind as to why should a small child have back pain so if there is a very young child say a five-year-old or eight or ten-year-old who says back pain then we need to investigate we need to get at least an x-ray to look for some kind of congenital anomalies children will you'll be surprised there how uh how uh plastic their muscles are how how resistant they are to uh stresses and strains that uh it's very unusual but yes for children again now you they should be allowed to play outdoors as much as possible or indoors or at least engage them in some kind of uh conditioning exercise like um a dance session for half an hour so that all their muscles are toned up and uh you know optimized if they are only having online classes and not going out to play they they they can over three to five months they can definitely have poorer uh muscle mass and muscle growth muscle strength compared to what they would have been if they were not confined to their home so yeah let them do something fun even inside the house like a dance session for half an hour 45 minutes and that should help them in in strengthening their muscles um how next question is how to distinguish muscle pain and real bore issue in case of back pain uh which comes from any kind of sports that's a that's a good question so a pain which is very sharp with with any movement of this kind and at times even every time you cough or breathe inhale or exhale deeply if you have a sharp kind of pain now that's something which you have to uh consider think that it is not just muscular and if the person is having rest pain whenever a person is lying still in on the bed not doing anything horizontal position and still having pain now that could be something else other than just muscular because essentially muscular or mechanical problems or problems which are because of load being subjected on the spine need are are not that dangerous then it could be muscular or it could be something very simple like a small slip disc or annular tear but if there is rest pain then it could mean so many things to us like commonly we think of infection we like to pull out infections and tumors of the spine when a person says they have rest pain so rest pain is a very important feature another important feature is whether the back pain is associated with fever or weight loss or loss of appetite now that is a red flag there are certain red flag and this is one of them if you're having back pain along with fever weight loss loss of appetite you need to see a specialist and you need some basic investigations blood tests and x-ray or maybe even an MRI to be done yeah so that's a that's a very good question again another question are squats bad for the back good question so I would suggest that I squats are not bad for the back and neither are dead lifts okay actually for a person who doesn't have a spine problem it's okay to do low back strength even go to the gym and do dead lifts but provided it's done in a controlled fashion under supervision squats are very good for the whole muscles start with half squats keep us close to and just sit and get up sit and get up start that way and then get on down to full squats perfectly fine as long as it's done in a controlled manner now if you are a post surgery if you are already having a compromised spine like we have removed the disc or been operated for a spine fracture or TB of the spine where pus and bacteria have eaten up the bones of the spine in such a scenario definitely doing a half squat is still okay even in those conditions but definitely not dead lifts or full squats or twisting actions of the spine where you know if there are screws which are put in the spine which are which is into very soft bones not hard bones then it can lead to some amount of toggle and loosening of the implants if your luck is not good or a girl you know so better to avoid planks are the best form of exercise when in doubt and you can effectively improve your back muscles and your core muscles just by doing simple plants you don't really need to you know venture into heavy duty exercises and it can be done you know in a very natural position or lying down position you wake up in the morning and you do a plant session of plants in bed and only then get out of bed job done so any more questions muscle store emotional memory chronic pain do have emotional connection yes Dr. Jai Surya yes that's the that's a very relevant concept that you have brought up that's what that's what we call as central sensitization so a person has back pain it may be a simple muscular back pain but if it lasts for a long time what happens is to put in layman's terms more neurons in the brain are recruited by by the body to sense pain a pretty useless and mischievous process happening in our brain so there is an amplification of pain so the memory of the pain actually gives you more perception of pain and many of the individuals who have anxiety disorders can be susceptible to undue amplification of pain that is central sensitization and for such individuals with chronic pain there are central desensitizers like amitriptyline or many other medications which help in decreasing the amplification and which is important because the once the person who is anxious gets some pain relief they are more encouraged optimistic and then there is a chance that they can fight the back pain and restore their spine health yeah so how to distinguish so I hope that answers your question I think I have answered most of the questions yeah I hope I have not missed out on anybody's question and I think I enjoyed conducting this session I hope all of you enjoyed it too thank you one and all for joining in and you can please connect with us if you have any more doubts and we'll be happy to answer to all your queries thank you very much Mr. Shanmugam and I can leave that to Mr. Shanmugam for any appointment and suggestions thank you thank you