On completion of this program, you will be able to:

• Recognize the importance of self-responsibility in preventing back injuries.
• Demonstrate understanding of the importance of maintaining physical strength, flexibility, endurance, and mental health to prevent back injuries.
• Demonstrate understanding of how your body manages weight loads when lifting and apply principles allowing you to reduce wear and tear on your back.

Demographics

Low back pain affects 60-80% of us at some point in our lives. Up to 50% of us will have back pain some time this year! Symptoms of back pain are among the top 10 reasons for visits to physician's offices, outpatient departments, and emergency rooms. Even though symptoms are usually temporary, low back pain often recurs, and becomes chronic in 5-10% of patients.

Job satisfaction and psychosocial status are more direct predictors of job-related back injuries than the amount of lifting required in the job! If you want to reduce the risk of injury, you must control stress, depression, work conditions and job satisfaction. Knowledge and improved lifting techniques only go so far.

Why Nurses?

While there are the occasional and unpreventable accidents, most nurses injure themselves because of attitudes and failure to utilize good self-care habits.

Costs

This country pays $20-$25 BILLION annually in direct care costs for on-the-job back injuries! 20-30% of all worker compensation claims are related to back injuries consuming 40-50% of the dollars paid out in claims.

Many of us do not even think of the secondary losses that occur with back injury. When pain and immobility become significant factors in your life, participation and enjoyment of most daily, recreational and social activities are impacted.

Let's Take a Look

Nurses complain of back fatigue and pain from too much lifting, not enough help, lack of equipment, lack of time - and the list goes on. Nurses seldom complain about lack of training. Ask yourself these questions:

• What have you learned about proper lifting techniques in the past?
• What do you see as you walk through any health care setting and observe the staff moving patients, charting, making beds and doing activities that make up a typical day?
• What do you see when you observe yourself and your friends in daily routines?

The reality is nurses are always in a hurry. We are our own worst enemy. We leave equipment in the closet, ignore posture, don't have time for physical fitness and think cheating on our use of proper body mechanics won't hurt us. We are inconsistent in using help because we are thinking "I can do it," or "everyone else is too busy."

The reasons and excuses are endless but the responsibility for self-care is yours - on and off the job! Back pain may be common, but it is not inevitable. You can break the cycle! Choose to take care of yourself and reduce the wear and tear on your back.

Education and ergonomics can decrease risk of injury in the short run. A change in attitude and approach is required for long term changes. All too often, the effects of training disappear within 2-3 months and most people revert to old habits.

Take Care of Yourself

Knowing your risk factors and taking care of yourself is the first step toward reducing your risk of back injury. Start by doing an HONEST assessment of your knowledge, habits and self-care.

• Can you identify the natural curves of your back?
• Can you identify the muscles used when you are lifting?
• Do you use gravity and body weight for counter balance when transferring patients?
• Do you balance loads so as to avoid excessive strain?
• Do you stretch and warm up before engaging in strenuous or lifting activities?
• Do you plan and organize your lifting activities utilizing appropriate equipment and assistance?
• Do you exercise regularly and include exercises which improve the strength and flexibility of your spine?
• Do you know how to maintain the natural curves of your spine when sitting, standing, lifting and sleeping?

Guess Who's Back is Under YOUR Care?

If you did not answer yes to all of the previous questions, there is opportunity for improvement. You can reduce your risk by:

• controlling your risk factors.
• understanding how your back works.
• using proper techniques when lifting.
• utilizing an exercise routine to promote fitness and flexibility.

Identify Your Risks

• Sitting is harder on your back than standing. The weight load increases even more when your posture is poor and your back is unsupported.
• Excess weight added to poor posture increases the strain and makes you more vulnerable to injury. A sway-backed, pot-bellied posture is a symptom of weak muscles. Weak abdominal muscles often mean weak back muscles, too. Your spine cannot maintain it's natural curves when compensating for this type of posture. The result is increased stress to supporting structures and chronic wear and tear.
• Working in a stooped position for extended periods of time (gardening, vacuuming, bed making, shoveling, etc.) increases your likelihood of sustaining injury. Stooping causes a significant strain to be placed on the lumbar spine. McKenzie notes that you are particularly vulnerable during the first four to five hours of the day.

• Poor posture in any position strains the supporting structures of your back increasing fatigue and allowing poor alignment. Most back pain results from wear and tear resulting in chronic stress and strain. It is often related to long-term problems with posture, lifting techniques and repetitive motions.

Check your posture by using a full-length mirror or a friend with a camera, assess your posture while standing, sitting, lying down and lifting. How do you sit while watching TV, charting, driving, eating, or working on the computer? What did you do different because you were being observed? Do you maintain your natural curves and stabilize your pelvis while lifting patients, your child, your groceries, your bowling ball (or doing other household and recreational activities)?

Poor lifting techniques increase pressure on discs.

• How many protective strategies do you use while lifting to decrease your risk of injury?
• Do you plan your lifting activities before starting?
• Do you use a wide base of support and utilize assistance or equipment as needed?
• Do you hold objects close to your body and avoid twisting at the waist?

Bending your knees alone is not enough to decrease pressure on your back while lifting. When you back is rounded, the pressure on your discs is much higher than when your back is held upright with proper alignment.

Seldom do single lifting events cause a back injury. It is incorrect movements and lifting all day long during work, home and recreational activities that create cumulative damage to the back. Remember: You are at risk for a sudden injury if you are lifting a heavy object incorrectly.

Evaluate the effects of everyday strains on your back:

• Does your neck ache after working for a significant amount of time at the desk or computer?
• Does your backache at the end of the day when you are fatigued?
• Do you regularly ignore minor aches and pains in your back and neck-your body's signal that something is wrong, out of alignment, fatigued or stressed?
• Are you a weekend athlete or gardener exposing your body to extra stresses and strains? Do you have lots of extra aches and pains on Monday morning?

Exercise and conditioning, combined with proper body mechanics, can significantly decrease everyday stress and strains on your back.

• Are you aware of the impact of stress and fatigue on your performance and posture?
• Do you acknowledge the increased risk of making mistakes when you are fatigued or distracted by the stresses of your life?
• Do you prepare adequately for your shift or other activities by getting enough sleep or compensate for fatigue with stimulants (caffeine, etc.) which do not improve your judgement or concentration?
• Does your backache at the end of the day, especially when you are fatigued?
• How does your posture reflect your fatigue level?
• Do you understand the effects of stress and strain in your work environment, on your attitude, techniques and concentration? On your tolerance to small things which have gone wrong?

Controlling your stress is critical to your success and recovery if you do have back pain. Ask any employee health nurse and they will tell you those employees who have a chronically stressed lifestyle and are having difficulty coping are those who are primed for injury and have the most difficulty with compliance and recovery.

The effects of aging affect us all.

Your Spine (Cervical, Thoracic, & Lumbar Curve)

The healthy spine aligns itself in three natural curves. It supports your upper torso, protects your spinal cord and provides a point of attachment for your muscles and ligaments. It is flexible, balanced and pain free. It is supported by strong back, abdominal, buttock and leg muscles.

The lower back has adapted to upright posture through the development of larger vertebrae throughout the lumbar curve (L1-5) which are able to bear the body's weight.

You need to remember that you really do need to support balanced alignment of your spine in all positions: sitting, standing, lying down, lifting, moving, etc…

Take A Closer Look

Let's take a closer look at the spine:

• Strong ligaments surround the vertebrae supporting and stabilizing them.

• Intervertebral discs function as shock absorbers, changing shape and allowing vertebral joints to move smoothly on each other.
• Spinal nerves exit the spinal canal via the round foramena openings between the vertebrae.
• Pain occurs when nerves complain about abnormal stresses in the area. Muscles, trying to protect the spine by immobilizing the area, respond with spasms. As spasms continue, pain and stiffness increase.

Ruptured discs cause severe pain due to the pressure placed on the spinal nerves and are often disabling. If the pressure continues, nerve damage occurs, resulting in numbness and weakness.

Maintaining Those Curves…

The key to preventing most back pain is maintaining your natural curves. Proper posture is key to maintaining a balanced spine and avoiding strain to supporting ligaments and muscles. Posture supports the natural curves of your back when a straight line can be drawn through your ear, shoulder, hip and ankle while standing. It allows the lumbar spine to bear the weight of the upper body and transmit this weight through the pelvis and lower extremities. This weight distribution sets up your pelvis and lumbar spine to function as a fulcrum during lifting activities. By setting your pelvis, you stabilize the fulcrum and decrease stressors on the lower back.

Setting your pelvis prepares and protects your back from strain during lifting activities. Learn to set your pelvis by standing with your feet shoulder width apart, your knees slightly bent and:

• rotate your pelvis to the back as far as possible....
• rotate your pelvis to the front as far as possible...
• rotate your pelvis to the most comfortable neutral location between the two while keeping your knees slightly bent. Keep your pelvis in this neutral location and use your legs to do the lifting.

Bearing the weight…

When you increase weight loads by picking something up, your trunk muscles contract to provide stabilization and support to your spine - not to provide lifting power! How you choose to lift the load determines the relationship of the lever (your arms) to the fulcrum (your pelvis) and the amount of force required to lift it. One of the best things you can do for your back is to increase the strength of your abdominal muscles so they can provide support to your spine.

May the Force Be With You…

An object held further away from your body requires more force to lift. In addition, your lower back (the point of the fulcrum) must take more stress to compensate for the long lever arm. This generates a tremendous amount of strain on the lower back area. In addition, your trunk and pelvic muscles must work hard to maintain your balance and keep you from falling forward due to your posture and the weight of the object you are lifting.

Test it out! Experience lifting force:

Fully extended, the amount of work required to hold the book increases exponentially-taking up to 10 times the work of holding the book close to your body.

Remember the greater the distance between you and the object, the more force required. The maximum torque of that force occurs at the point where the lever sits on the fulcrum; your lumbar spine. Rounding your back instead of keeping it in its natural curves also increases the stress on your lower back. Squatting and using your legs means the lever is shorter and stronger!

Proper Body Mechanics

Learning to use proper body mechanics is like learning any other motor skill. It requires practice and may feel odd and uncomfortable until the skills are developed. A good place to start is learning to support your natural curves by using good posture during lifting, standing, walking, sitting, and sleeping activities.

Standing and Walking

Stand with your back against a wall. There should be only minimal space between your back and the wall. Both slouched postures and standing at attention (military stance) alter the natural curves and strain your back.

• Stand tall.
• Slightly tuck chin.
• Hold in stomach.
• Rotate pelvis to align in natural curves.
• Wear comfortable, low-heeled shoes. Platform and high-heeled shoes place extra strain on your pelvis and lumbar spine. They are also hard on your feet.

You can decrease back fatigue when standing for long periods by changing positions and propping a foot up 6-8 inches (which encourages natural lordosis of the lumbar spine).

Most furniture does not support your body's natural curves. When buying furniture or cars, consider lumbar support in the style and make of the products. Anyone who spends a lot of time in a chair is at particular risk for development of back pain.

• Use a lumbar support for extended sitting.
• Chair height should allow both feet to sit flat on the floor with knees level with hips.
• Sit with pelvis all the way back in the chair.
• When driving, move the seat forward so you are not reaching for the steering wheel.

You can rest your back and relieve stress placed on your spine from extended sitting or standing by doing stretching and resting exercises.

The following exercises can be used to stretch and rest your back:

Sleeping

A good night's sleep is good for you, your body and your brain. Soft, saggy mattresses, couches and lounge chairs encourage swaybacks and increase back strain. Use a firm, supportive mattress instead. Sleep on your side with knees bent, back and neck in alignment, head supported in a neutral position. If you are sleeping on your back, place a pillow under your legs to take the stress off of your lower back.

Most Americans and Europeans are sleep deprived and have been becoming progressively more so since the advent of the light bulb followed by assembly lines and shift work. Even small amounts of sleep deprivation impair our mental functioning and tolerance to everyday stresses and strains. Getting as little as 6.5 hours of sleep per night increases your risk of poor judgement and injury. Consider this as you pass your meds and drive home from work.

Those who work day and evening shifts are sleep deprived from shorting sleep time to complete projects, socialize and get chores done. Those of us who rotate shifts seldom prepare for the rotation and sleep just enough to get by. It is suggested you will generate less sleep debt if you rotate forward rather than backward (days to eves rather than eves to days).

Night shift workers should avoid rotating, staying consistently on nights, to be healthy and alert. If you have to rotate to night shifts and have trouble sleeping and staying awake, try taking a nap for two hours before you go in and go to bed when you feel drowsy the next day. Night shift workers will sleep better if the sleeping environment is dark, quiet and uninterrupted. Interruptions interfere with the quality of deep sleep that is necessary for rejuvenation of your mental functioning. They will also be healthier, happier and will function at their full capacity if they make sure they consistently sleep at the same time each day - even on their days off!

And a word of warning to those of you on 12 hour shifts; studies have shown a considerable sleep debt is developed during the workweek. Fatigue and decreased alertness are common during each shift (you know that) and they become worse as the workweek progresses. Performance decreases, and errors increase after 10 hours of work. Workers miss bits of information and have difficulty processing information that presented no difficulty earlier in the shift. Errors in judgement, impaired concentration and a higher susceptibility to accidents are common.

Lifting

You have all heard this before; think through lifting activities before doing them to make sure you have the resources to do them safely. Position your feet for a broad base of support.

Set your pelvis so that natural curves are kept and supported. Lift with your legs; those muscles are stronger anyway. Hold objects close to your body. Avoid added stress on your back by not lifting heavy items above your chest. Hold the item close to you and use a stool to avoid reaching over your head. Nurses have a very difficult time applying the concept of holding objects close to their body when the object is a patient. If you are afraid of contamination, wear appropriate protective clothing and get in there where you belong when you are doing transfers.

Plan ahead by using equipment and assistive aids appropriately. Set your pelvis, bend your knees, while keeping your back straight and avoid twisting at the waist. "Lift only what you can't pull and pull only what you can't push."

Cardiovascular fitness provides many benefits. Strength and flexibility training not only helps protect your back, it heightens your reactions and increases bone density.

• Build strong, flexible supporting muscles.
• Exercise every day.
• Build endurance and strength gradually, avoid overdoing it.
• Use a 2-3 minute warm-up.
• Include aerobic activities that maintain your Target Heart Rate for at least 20 minutes.

Your Target Heart Rate

Calculate your target heart rate with the following formula:

The American College of Sports Medicine recommends exercising at 60-90% of your maximum heart range. The .80 indicates your target at 80% of your maximum range. To determine your heart rate range for cardiovascular conditioning, multiply by .60 and .90 respectively.

It is suggested you do stretching exercises before every shift (and other physical activities and exercises) to decrease the risk of muscle injuries.

The following exercises can be used to stretch and strengthen your back and increase your flexibility. They are easy, fast and require no extra equipment. When done for 15 minutes 3-5 times per week, they will assist you in staying conditioned and balanced. Always warm up by stretching and limbering your body. Try lying on your back and alternately moving each extremity, tightening and relaxing muscles. Include cardiovascular conditioning exercises for a well-rounded workout!

From a starting position of lying on your stomach with your arms at your side, lie with your head turned to one side and relax for 3-5 minutes. Turn your head and repeat on other side. Then prop yourself up on your elbows and relax for 2-3 minutes for a slow stretch of your lower back. Return to the starting position and relax for a minute. Repeat the process up to 5 times while keeping your lower back relaxed.

This is an advanced strengthening exercise. If you are currently suffering from back pain, please check with your physician or therapist before continuing. From a starting position of lying on your stomach with palms flat at your shoulders, do a partial push-up while keeping your pelvis on the floor. Hold it for a 5 count and then slowly return to the floor. Repeat 5 times while relaxing your lower back and legs.

From a starting position of sitting with your legs extended with heels less than 6 inches apart, bend from the hips in an easy stretch and hold it for a 20 count. Repeat 5 times, stretching farther each time trying to touch your toes.

From a starting position of lying on your back with your knees bent and feet flat on the floor, raise your right knee to your chest for a 5 count then lower it. Repeat 5-10 times. Do the same with the left leg and then with both legs.

From a starting position of lying on your back with knees bent and feet flat on the floor, slowly reach forward with your hands while curling head (keep your head in line with your shoulders) and neck to chest and hold for a 5 count. Slowly return to starting position. Repeat 5-10 times.

From a starting position of lying on your back with your knees bent and feet flat on the floor, press lower back into the floor by tightening your abdomen and buttocks and hold for a 5 count. Repeat 5-10 times.

From a starting position of lying on your stomach with hands on hips, stiffen and raise one leg slowly from the hip and return to floor. Don't lift your pelvis in order to raise your leg and keep your leg straight. Repeat 5-10 times and switch to other leg.

If you should develop a backache, take care of it with rest, icing, anti-inflammatories and slow stretches. Stop and determine the causative factors. If your posture, technique or conditioning are at fault, correct it once the pain has diminished in order to prevent reoccurrence and more wear and tear on your back.

• Rest and avoid lifting or other activities that increase pain.
• Place icepacks on the sore area for 15-20 minutes, several times per day.
• Stretch slowly every few hours to maintain range of motion and avoid stiffness.
• Take anti-inflammatories, but remember to allow enough rest time to avoid added strain while the medication is making you feel better.
• If your pain continues, worsens or is severe, see your physician!

References

Coren, Stanley. Sleep Thieves: An Eye-Opening Exploration into the Science and Mysteries of Sleep. New York, NY: Free Press. 1996

Daltroy, LH, Iverson, MD, Larson, MG, et al. Teaching and social support: effects on knowledge, attitudes, and behaviors to prevent low back injuries in industry. Health Education Quarterly. 1993. (20)43-62.

Dehlin, O, Berg, S, Hedinrud, B, et al. Muscle training, psychological perception of work and low back symptoms in nurses aides. Scandinavian Journal of Rehabilitation Medicine. 1978. (10)201-209.

Gundewall, B, Lijeqvist, M, Hansson, T. Primary prevention of back symptoms and absence from work. A prospective randomized study among hospital employees. SPINE. 1993. (18)587-594.

McKenzie, Robin. Treat Your Own Back. Spinal Publications New Zealand LTD. 1997

McKenzie, Robin. Treat Your Own Neck. Spinal Publications New Zealand LTD. 1997

National Institute for Occupational Safety and Health. Back belts: do they prevent injury? Washington, DC: National Institute for Occupational Safety and Health, 1994. (DHHS (NIOSH) Publication no. 94-127.)

Videman, T, Rauhala, H, Asp, S, et. al. Patient handling skill, back injuries, and back pain: an intervention study in nursing. SPINE. 1989. (14)148-156.

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To earn 1.5 Continuing Education contact hours please send this answer sheet along with a check made out to Rehab ClassWorks for $10 (UNA Members) or $15 (Non-UNA Members) to:

Continuing Education Questions:

You know you are using good posture when:

1. Your back is balanced and your pelvis aligns with your knees.
2. You stand tall with extreme lordosis and use a wide base of support.
3. You are standing tall with your shoulders rounded, stomach held in and pelvis aligned to support your spine's natural curves.
4. You are standing tall with your chin slightly tucked, stomach held in and pelvis aligned to support your spine's natural curves.

The amount of force required to lift the load is minimized when you hold the object close to you because the distance between the line drawn through the point of the fulcrum and the line drawn through the object being lifted are:

1. Close together.
2. 18 inches apart.
3. Maximum distance apart.
4. Equal to the length of the lever (your arm).

Your pelvis and lumbar spine function as a fulcrum during lifting activities which means:

1. They are chronically unstable.
2. They contract to bear the weight of the object lifted.
3. They are the support about which the lever (your arms) turn.
4. They redistribute weight load to the arms (the lever) when lifting occurs.

You can tell if your standing posture is correct by identifying whether a straight line can be drawn through your:

1. Ear, shoulder, hip and ankle.
2. Chin, shoulder, hip and ankle.
3. Chin, elbow, knee and ankle.
4. Ear, shoulder, knee and heel.

Most furniture:

1. Is effective in supporting the spine and proper posture when sitting.
2. Is adjustable to individual height and weight allowing proper posture when sitting.
3. Does not support the spine or proper posture when sitting.
4. Allows you to relax without worrying about posture.

You can improve your posture and decrease strain on your back when sitting for extended periods of time by:

1. Using a lumbar support and sitting with your pelvis all the way back in the chair.
2. Elevating your legs.
3. Moving your seat back when driving so that arms are fully extended.
4. Using a chair height that increases hip flexion and elevates knees.

Consistently failing to get enough sleep (8 or more hours per night):

1. Puts you and your patients at risk.
2. Impairs your concentration and judgement and makes you more irritable.
3. Increases your fatigue and therefore encourages you to shortcut or miss details increasing your risk of injury during transfer activities.
4. All of the above.

The most common factor contributing to back pain is:

1. Occasional stresses and strains.
2. Sitting in a chair with a straight back.
3. Stooping which increases strain to the cervical spine.
4. Poor posture.

You can significantly reduce your risk of back injury by:

1. Bending with your legs straight.
2. Regularly sleeping on a very soft mattress while lying on your stomach to maximize lumbar lordosis.
3. Ignoring small aches and pains, they seldom have any significance.
4. Honestly assessing your knowledge, habits and self care practices.

You can decrease your risk of back injury by:

1. Controlling your risk factors.
2. Understanding how your back works.
3. Utilizing an exercise routine to promote flexibility and fitness.
4. All of the above.

Spinal nerves:

1. Exit the spinal canal via the articulating surfaces.
2. Rupture due to age, an unavoidable process that goes unnoticed in those with good posture.
3. Are often torn during lifting activities resulting in immediate pain.
4. Exit the spinal cord via the foramena.

Back injury prevention is:

1. My manager's responsibility.
2. The responsibility of risk management.
3. My responsibility.
4. My facility's responsibility.

A good sleeping surface is firm enough to support your body in good spinal alignment. It is suggested that you:

1. Sleep on your stomach to stretch your back passively while sleeping.
2. Place two pillows under your head to support the thoracic curve.
3. Place a pillow under your legs while lying on your back and sleep on your side with your knees bent and head supported in a neutral position.
4. Replace your mattress every two years because most mattresses are worn out by then and provide little support to your spine.

Back pains occurring several hours after strenuous activities may be the result of:

1. Damage that occurred during the strenuous activity.
2. Spinal distortion which occurs during resting when postures do not support natural curves of the spine.
3. Spinal distortion which occurs during activities when postures support curvature of the spine.
4. Sedentary lifestyles with brief periods of heavy exercise.

One quick way to check your standing posture is to:

1. Stand against the wall and slide down it, making sure you can press your lumbar spine flat against the wall.
2. Stand with your back against the wall and check to make sure there is minimal space between the small of your back and the wall.
3. Stand at attention (military stance) and determine the length of time till fatigue sets in.
4. Stand against the wall with hands over your head and determine the amount of lordosis that results in the lumbar area.

Most nurses:

1. Have had little exposure to proper body mechanics.
2. Have had multiple exposures to proper body mechanic techniques.
3. Have difficulty accessing proper training for body mechanics.
4. Complain that they have not had an opportunity to learn proper body mechanics.

The lumbar vertebrae are larger and stronger because they.

1. Are the source of much twisting and turning.
2. Are associated with the large bones of the pelvis.
3. Have adapted to the extra weight they must carry to support our upright posture.
4. Have more nerves exit through their vertebrae than elsewhere in the spinal column.

The most direct predictors of job-related back injuries are:

1. Job satisfaction.
2. Amount of lifting required in the job.
3. Availability of training and practice in lifting techniques.
4. Ergonomically correct working stations.

Intervertebral discs:

1. Surround, support and stabilize the vertebra.
2. Are the spine's shock absorbers.
3. Force the vertebra to stay in alignment.
4. Cause little pain when ruptured, as they have no nerve endings.

If you are chronically stressed at home or on the job:

1. Your risk of injury is decreased.
2. You may have a more difficult time recovering from an injury.
3. You will be more likely to comply with an exercise and training program.
4. You will be unlikely to have muscle spasms.

If you know you will be doing a lot of standing and walking, you can decrease the strain on your back by:

1. Wearing comfortable, low-heeled shoes.
2. Changing positions regularly.
3. Propping your foot up about 6-8 inches to support your lumbar spine.
4. All of the above.

How many natural curves are there in your back?

1. One.
2. Two.
3. Three.
4. Four.

In addition to good posture and proper body mechanics, you can decrease your risk by:

1. Exercising to build strong, flexible supporting muscles in your back.
2. Jogging and playing active sports to increase endurance.
3. Increasing seated time so that your back is rested and supported prior to lifting activities.
4. Increasing calcium intake to promote bone density and slow the development of osteoarthritis.

Most back pain results from:

1. Athletic injuries.
2. A single traumatic event.
3. Chronic wear and tear from long term problems with posture and lifting techniques.
4. Sedentary jobs with brief periods of heavy lifting.

Foundation skills for proper body mechanics include:

1. Avoiding fatigue and maximizing lumbar lordosis.
2. Using proper posture when standing and focusing on rounding your back during lifting activities.
3. Using good posture, understanding and supporting alignment of your spine's natural curves.
4. Resting on supportive surfaces at least 4 times per day.

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