Alternative medicines

As children we have the great gift of a mobile, strong, well designed and painless spine and it is unusual for stiffness to be an issue as the lumbar spine has evolved to do the job of weight bearing and providing movement. Intervertebral discs separate the spinal vertebrae, allowing more movement in areas where they are thicker and also coping with variable loads. The posterior spinal facet joints limit and control segmental movement, preventing the spine from displacing inappropriately under the shear forces. Strong, balanced and coordinated muscle actions complete the picture.

An acute episode of low back pain inhibits the core stabilising muscles from working well and can cause wasting of them with time. Segmental loss of stability control can make the occurrence of further low back pain episodes at the same level more likely. As time and injuries change the spine, degenerative changes can occur in the facet joints and discs, leading to segmental stiffness and chronic back pain. The force of gravity pushes fluid from the discs by compression and is opposed by a chemical absorption of fluid which is more powerful in lying.

As compression forces tend to be more powerful as time goes on, dehydration of the disc occurs to some extent as it narrows and stiffens. This can be imaged on x-ray but the disc is likely to show changes and painful problems long before the results can be seen on x-ray. A segment is defined as two adjacent vertebrae and the intervening intervertebral disc, an altered disc contributing to an abnormal segment which moves abnormally and pushes abnormal loads onto tissues where they are not designed to take them. Physiotherapists can feel the restrictions in spinal movements which occur when a stiff segment limits segmental excursion.

Protective muscle spasms are common after an injury and this splints the affected area and allows the process of inflammation and healing to get started. With the gradual resolution of the injury and its pain reduction the amount of back spasms normally lessens and slowly normal movements begin to be apparent again. But muscles can remain in muscle spasm in some cases, leading to a stiffened and shortened group of spinal structures which, by this adaptive shortening, leads to the production of shortened and abnormal spinal joints, ligaments and muscles.

Increase of the compression forces through the spine can be promoted by sitting for long periods, leading to increase in the fluid loss from the discs. Discs rely on us repeatedly bending forwards for disc health and nutrition and avoidance of this movement compromises disc wellbeing, leading to an increased potential risk of degenerative change. A weakness in the abdominal muscles and the development of abnormal postures also contribute to these problems.

A typical history is to have an episode of severe low back pain which gradually develops into a segmental stiffness problem. The stiff areas may be present asymptomatically for many years in many individual areas of the spine before one of them develops into a painful segment which causes restriction. Sitting for a long time or spending time bent into flexion will tend to aggravate this condition once established as joints are moved beyond their comfortable limits. The lumbar facet joints become fixed into extension and the whole segment suffers from adaptive shortening, forfeiting its ability to move normally. I have back problems very like this and it can be quite difficult, forcing me to limit heavy or repetitive work or any significant time in flexion.

Sarah Key, a physiotherapist who is well known in the UK, has produced the Sarah Key’s Back Sufferers Bible, a book in which she sets out her views of what is going on in this most common of musculoskeletal syndromes. She does acknowledge that it is hard to bring solid evidence for many of her interpretations but seems to have many good and practical therapy ideas to approach the back pain problem with. She covers the main syndromes which typically occur, giving treatment routines for self management of each one, all of which I have found very useful for my own lower back pain. Now I have something I can do about it rather than accept it as a fact of life.