Josh Pitzalis

Dealing with a stiff back

This post outlines my fascination with the design of the human spine. It will show you how to protect your spine at your segmental level. If you spend more than an hour or two sitting down each day, then this is useful information.

A healthy spine comes into the world compressed into the smallest shape possible. In the womb, our bodies are designed to take up as little space as possible. Our backs are coiled into a c-shaped curve, the head tucked in, and our limbs scrunched together.

As babies, we lift our heads up to look at the world around us. This one movement alone has a dramatic effect on the shape of our spine. The weight of the head pushes a gentle bend into the top of our spine. Eventually, we learn to stand up. The shift from horizontal to vertical has a tremendous impact on the way our spine handles our body weight and causes the lower section to buckle and bend inward.

These two curves bend the spine into an s-shaped structure. This s-shape structure stacks the spine in equilibrium and allows it to act like a spring. It ensures that pressure runs evenly through the front and back compartments while allowing it to absorb shock from movement.

The spine is made up of 24 little chunks. Each chunk has a large circular front compartment and another smaller back compartment with three boney projections. The back compartments bear approximately 16% of our body weight but can withstand up to 70 % when they need to. This extraordinary resilience comes from its ingenious design. Each chunk is narrow at the waist and flares out into the broader upper and lower surface. The outer casing of each segment is encrusted in hard bone, while the inside is made of a honeycomb-like scaffolding. The honeycomb center is filled with a rich supply of blood that helps disperse impact through the bone. This allows the spine to bear immense weight yet at the same time remaining light and mobile.

Each little chunk of the spine is separated by a disc that acts like a small water-filled cushion. These cushions facilitate the spine’s spring-like function. Each one is designed to allow for maximum flexibility while stabilizing the column and retaining its mechanical integrity.

The center of each fluid-filled cushion functions like a hydraulic sack, distributing force evenly in all directions. This allows the spine to twist and bend without crushing itself. The outer layer of each pillow’s casing is arranged in an onion-like fashion. Each layer diagonally opposes the other. This makes the casing extremely strong but also allows the sides to elongate as the spine bends.

If the center of one of these cushions deteriorates, it will rip through its casing and bleed onto the surrounding nerves. This can be so intense that it radiates from the site of damage and carves a rill of pain down the length of one or both limbs. Sometimes people lose the ability to walk altogether. Other times movement is restricted to a mere hobble.

A thin group of muscles and ligaments closest to the spine create a protective shield that scaffolds that spine at a segmental level. These muscles make up what is called the ‘deep unit’.

Exercising the deep unit is simple. One simple exercise, called a position sensing exercise, strengthens the spine and supports your back at the segmental level. The exercise involves sitting on a stability ball (one that is big enough for your hips and knees to be parallel when sat down). The aim of the exercise is to lift one leg off of the floor and keep your pelvis perfectly level and still while you are doing it. The goal is to be able to keep each foot off the floor for a full minute without any shaking or moving whatsoever.

Josh Pitzalis

If you can perform the exercise easily, then make it harder by closing your eyes. If you want to take the exercise even further, perform the exercise with your stable foot (which is the one on the floor) balanced on a small ball.

Even the smallest amount of effort will start reversing any existing deterioration. Movement at the segmental level stimulates the synthesis of proteins that help replenish vital fluid in your spinal disks. Polyriphyl proteins absorb water into the disk when fluid levels start to drop. Incidentally, these proteins are only created by pressure changes in the spine. When we start to lose mobility, we restrict movement in the spine, and this results in an overall drop in fluid protein levels. Re-introducing controlled amounts of movement (even as little as two minutes twice a week) helps the spine synthesize new proteins. These proteins then help replenish the fluid in your disks, which allows for more movement and produces even more proteins.

This approach is most useful as a preventative measure for people who are not already in pain. If you are already in pain, you need to seek professional help. The rest of this post will outline what you options are in this respect.

When pain persists for more than 3 months, it is called chronic pain (1). Chronic pain is different from other kinds of pain because there are no evidence-based guidelines to manage it. A simple 3 stage approach can help minimize the amount of time and money wasted when exploring your options (2). Each stage is somewhat riskier than the previous and therefore should only be explored once the previous stage has been exhausted.

Stage 1- Therapy

Massage therapies are the only therapies that have shown any evidence of effectively aiding recovery from chronic lower back pain. Massage has proven to be more effective than sham therapy, self-care, acupuncture muscle relaxation, and remedial exercise (3).

• Acupuncture (15) and Hydrotherapy (18) were shown to be no more effective than sham treatment, placebo, or being put on a waiting list.

• Behavioural therapy is better than no therapy or placebo, but it is not better than exercise therapy, nor does it provide any additional benefit when added to other interventions (16, 17).

• Exercise therapy is more effective than usual care by a GP (18), although the evidence is conflicting on whether it is more effective than a sham treatment (15,19).

• Manipulative therapy was found to be slightly more effective than sham treatment but no more effective than any other forms of therapy (19, 15).

• Multidisciplinary therapy has shown promising reviews for chronic pain in general (20), but its efficacy for chronic lower back pain is less promising. (21)

Stage 2- Drugs

• Pain killers may be of short-term benefit, but there is no published data to support their long-term use for chronic lower back pain (1,5,6)

• Antidepressants may be slightly more effective than a placebo for relief from chronic lower back pain but have not been tested for longer than 8 weeks (7).

• Opioids may be more effective than a placebo for relieving chronic lower back pain (8), but the average effect is just over a 10-point reduction on a 100-point scale (9,8)

• Interestingly, Willow bark has been shown to be more effective than placebo and as effective as non-steroidal anti-inflammatory drugs for treating relapses of recurrent low back pain (10,11).

Stage 3- Surgery

The following surgeries have been deemed effective in aiding recovery from chronic lower back pain. Unfortunately, degenerative changes alone are not considered a valid source of pain because there are just as many people with degenerated backs who don’t complain of pain. There are two sources of pain (listed below) for which surgery seems to be of help.

• Internal Disc Disruption can be diagnosed with the help of Provocation and computed tomography discography (1). Treatment for internal disc disruption has traditionally been Arthrodesis. However, its questionable efficacy has prompted minimally invasive alternatives. Intra-discal electrothermal therapy (IDET) is one such alternative, in which the fissures of the painful disc are coagulated with flexible electrodes introduced into the disc (12).

• Joint Blocks can be used to diagnose pain from the sacroiliac joint or the lumbar zygapophysial joints (1). Blocks thought to be the source of the pain can be anesthetized by injecting a local anesthetic into the joint or by blocking the nerves that supply the joint. Zygapophysial joint pain can also be treated with Radiofrequency medial branch neurotomy (1,13,14)

What if surgery doesn’t work?

Patients with chronic low back pain who fail to benefit from surgery can be difficult to treat. These patients have generally been treated with multidisciplinary therapy, spinal cord stimulation, or intraspinal opioids. Although some patients can benefit from each of these approaches, they have not been universally successful(1).

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References

  1. Bogduk N, McGuirk B. Medical management of acute and chronic low back pain: an evidence-based approach. Amsterdam: Elsevier, 2002.

  2. This approach is based on Tim Ferriss’s Approach to reversing ‘permanent’ injuries in his book the 4-hour body.

  3. Cherkin DC, Sherman KJ, Deyo RA, Shekelle PG. A review of the evidence for the effectiveness, safety, and cost of acupuncture, massage therapy, and spinal manipulation for back pain. Ann Intern Med 2003; 138: 898-906.

  4. O’Sullivan PB, Twomey LT, Allison GT. Evaluation of specific stabilizing exercise in the treatment of chronic low back pain with radiologic diagnosis of spondylolysis or spondylolisthesis. Spine 1997; 22: 2959-2967.

  5. Van Tulder MV, Goossens M, Waddell G, Nachemson A. Conservative treatment of chronic low back pain. In: Nachemson A, Jonsson E, editors. Neck and back pain: the scientific evidence of causes, diagnosis, and treatment. Philadelphia: Lippincott, Williams and Wilkins, 2000: 271-304.

  6. Van Tulder M, Malmivaara A, Esmail R, Koes B. Exercise therapy for low back pain. A systematic review within the framework of the Cochrane Collaboration Back Review Group. Spine 2000; 21: 2784-2796.

  7. Salerno S, Browning R, Jackson SL. The effect of antidepressant treatment of chronic back pain. A meta-analysis. Arch Intern Med 2002; 162: 19-24.

  8. Jamison RN, Raymond SA, Slawsby EA, et al. Opioid therapy for chronic non-cancer back pain. A randomized prospective study. Spine 1998; 23: 2591-2600.

  9. Moulin DE, Iezzi A, Amireh R, et al. Randomised trial of oral morphine for chronic non-cancer pain. Lancet 1996; 347: 143-147.

  10. Chrubasik S, Eisenberg E, Balan E, et al. Treatment of low back pain exacerbations with willow bark extract: a randomized double-blind study. Am J Med 2000; 109: 9-14.

  11. Chrubasik S, Kunzel O, Model A, et al. Treatment of low back pain with a herbal or synthetic anti-rheumatic: a randomized controlled study. Willow bark extract for low back pain. Rheumatology 2001; 40: 1388-1393.

  12. Bogduk N: Management of chronic low back pain. Med J Aust 2004, 180:79-83

  13. Van Kleef M, Barendse GAM, Kessels A, et al. Randomized trial of radiofrequency lumbar facet denervation for chronic low back pain. Spine 1999; 24: 1937-1942.

  14. Dreyfuss P, Halbrook B, Pauza K, et al. Efficacy and validity of radiofrequency neurotomy for chronic lumbar zygapophysial joint pain. Spine 2000; 25: 1270- 1277.

  15. Cherkin DC, Sherman KJ, Deyo RA, Shekelle PG. A review of the evidence for the effectiveness, safety, and cost of acupuncture, massage therapy, and spinal manipulation for back pain. Ann Intern Med 2003; 138: 898-906.

  16. Bogduk N, McGuirk B. Medical management of acute and chronic low back pain: an evidence-based approach. Amsterdam: Elsevier, 2002.

  17. Van Tulder MW, Ostelo R, Vlaeyen JWS, et al. Behavioral treatment for chronic back pain. A systematic review within the framework of the Cochrane Back Review Group. Spine 2000; 25: 2688-2699.

  18. McIlveen B, Robertson V. A randomized controlled study of the outcome of hydrotherapy for subjects with low back or back and leg pain. Physiotherapy 1998; 84: 17-26.

  19. Assendelft WJJ, Morton SC, Yu EI, et al. Spinal manipulative therapy for low back pain. A meta-analysis of effectiveness relative to other therapies. Ann Intern Med 2003; 138: 871-881.

  20. Flor H, Fydich T, Turk DC. Efficacy of multidisciplinary pain treatment centers: a meta-analytic review. Pain 1992; 49: 221-230.

  21. Guzman J, Esmail R, Karjalainen K, et al. Multidisciplinary rehabilitation for chronic back pain: a systematic review. BMJ 2001; 322: 1511-1516.

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