Back Pain: How to Build Core Stability for Long-Lasting Relief

by Adam Gavine, Rod Bonello

Overview

A self-help guide for sufferers of back pain who want long-lasting relief, with simple exercises which can be done at home

Back pain gets in the way of everything we want to do, and it can stop us sleeping too. It can be difficult to find the right treatment, and expensive to keep visiting a chiropractor, osteopath, physiotherapist, or masseuse. If you are looking for long-lasting relief from your back pain, or trying to avoid back problems, it's essential to treat the cause, not just the symptom. Research shows building your core muscle stability is the most effective way to deal with most forms of back pain. Drawing on their extensive clinical experience and the latest research, this book explains how to find the best possible treatment for one's back and get the most out of treatment. It provides safe exercises that can be can do at home to develop and maintain core muscle stability, illustrated by easy-to-follow photographs.

Product Details

ISBN-13:	9781743436899
Publisher:	Allen & Unwin
Publication date:	09/01/2014
Sold by:	INDEPENDENT PUB GROUP - EPUB - EBKS
Format:	eBook
Pages:	248
File size:	3 MB

About the Author

Adam Gavine is a chiropractor with special interest in sports medicine and spinal and functional rehabilitation. He represented Canada in decathlon and has experience working with top football and basketball teams, as well as members of the Canadian Olympic team. Rod Bonello is a researcher with an international reputation as a consultant in health care research. He is currently National President of the Chiropractic and Osteopathic College of Australasia.

Read an Excerpt

Back Pain

How to Build Core Stability for Long-Lasting Relief

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By Adam Gavine, Rod Bonello, Ian Faulkner

Allen & Unwin

Copyright © 2014 Adam Gavine and Rod Bonello
All rights reserved.
ISBN: 978-1-74343-689-9

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CHAPTER 1

Anatomy

A thorough knowledge of anatomy is fundamental for healthcare workers, and we think that some knowledge in this area would be useful to you too. If you're really not interested in this section, you can skip it — you can always come back to it later.

Spinal column

The human spinal column is made up of 33 individual bones, called vertebrae, and 23 intervertebral discs. The column is divided into five regions: cervical, thoracic, lumbar, sacral and coccygeal. Adults have seven cervical, twelve thoracic, five lumbar, five sacral and four coccygeal vertebrae. We are born with five sacral and four coccygeal vertebrae, these eventually fuse to form the sacrum and the coccyx in adulthood. The fusion process begins around 16 years of age and is usually completed by the age of 26. The spinal column provides a base of support for the head and internal organs, protects the spinal cord, and provides an attachment point for ligaments, bones, muscles, the rib cage and the pelvis. It serves as a linkage between the upper and lower extremities.

No two vertebrae are exactly alike. The size of the vertebrae and their corresponding intervertebral discs increase progressively from the cervical to the lumbar spine, due to the fact that the (lower) lumbar spine is required to bear greater loads. There are five transitional areas in the spine. Starting from the head they are the atlanto-occipital joint, the cervico-thoracic junction, the thoraco-lumbar junction, the lumbo-sacral junction and sacro-coccygeal joint. Transitional areas of the spine are areas where individual vertebrae and vertebral curves change from one shape to another. This generally occurs over the course of a few vertebrae. The cervico-thoracic junction, for example, is where the spine changes from a cervical to a thoracic vertebrae (C7 — T1). Transitional areas, as a general rule, have less range of motion than other areas of the spine. That is why they are often areas of interest when the spine is being treated by a practitioner. It is possible to have an extra vertebra or one too few due to a congenital anomaly. This most commonly occurs in transitional areas of the spine.

When viewed from behind (posterior), the spine ideally should appear in a straight vertical line. Any lateral curvature of the spine when viewed from behind is abnormal and is commonly referred to as a scoliosis; however, the lateral curvature must be at least 10 degrees curve radius to be deemed a true scoliosis.

Spinal curves

We are born with only one spinal curve, termed 'the primary curve'. It is a posterior or backward facing convex curve referred to as a kyphosis. During our first year of life, a secondary curve, which is forward or anteriorly convex (like the back of a spoon), termed a lordosis, begins to appear due to muscle development. The first lordosis begins to develop in utero, (as early as the seventh week) but does not become functional until the infant is able to hold the head upright. A second lordosis starts to form in the lumbar spine when the infant begins to push up when lying on its stomach. These two secondary curves continue to develop until growth stops at between 12 and 17 years of age.

When viewed from the side, the adult spine has a total of four anterior — posterior curves: two kyphoses (thoracic and sacral) and two lordoses (cervical and lumbar). While the degree of curvature varies from each section of the spine, there is a range for each section that is considered normal. Excessive or diminished spinal curves lead to adverse biomechanical and postural changes. Excessive curvature in the cervical or lumbar spine is referred to as hyperlordotic, while diminished curvature is referred to as hypolordotic. The same holds true with kyphotic curves: excessive = hyperkyphotic; diminished = hypokyphotic. Certain conditions cause excessive or diminished curves. A few of these common conditions are scoliosis, Scheuermann's disease, ankylosing spondylitis and diffuse idiopathic skeletal hyperostosis (DISH). All spinal curves are either 'structural' or 'functional'. Structural curves are unable to straighten while functional curves can straighten. The good news is that if your hyper/hypo curve is functional (not structural), it can be helped more easily. Structural curves can only be straightened with surgery, but can be treated mechanically with some success.

Vertebrae

Vertebrae, or vertebral segments, are the bony components of the spine. The human spine has 33 vertebrae. Each lumbar vertebral segment is composed of a vertebral body anteriorly, and the posterior elements at the rear. The vertebral body is the thick, box-like structure that sits between the intervertebral discs. It is bordered by the anterior longitudinal ligament in front and the posterior longitudinal ligament behind. The posterior elements include the pedicles that support lateral bony protrusions called transverse processes that connect to the laminae. The two laminae come together to form the bits that you can see or feel in the centre of the back. At the top and bottom these laminae are the superior articular processes of the lower vertebra that connects with the inferior articular processes of the vertebra directly above it. The internal girder-like structures made of bone are the trabeculae, which are found in a vertical or horizontal orientation. This crisscross patterning of trabeculae is what gives the vertebrae their tremendous strength and compressibility (see picture).

Spinal cord

The spinal cord is a thick cord of nerve tissue that gives rise to 31 pairs of spinal nerves and, with the brain, forms the central nervous system (CNS). Nerves that begin at the spinal cord and travel throughout the body make up the peripheral nervous system (PNS). The diameter of the spinal cord is approximately the thickness of a human adult finger. The spinal cord descends from the brain along the spine within a narrow passageway called the central canal, which surrounds and protects the delicate spinal cord.

The spinal cord is bathed in a clear fluid called cerebral spinal fluid (CSF), which cushions the cord during movement. The function of the spinal cord is to transmit electrical information to and from the limbs, trunk and organs of the body, as well as to and from the brain. The nerves that carry information from the body to the brain are called sensory nerves, and they relay information to the brain regarding skin temperature, touch, pain and joint position. The nerves that carry information from the brain to the body are called motor nerves; they send signals that control muscles. The spinal nerves exit the spine through small bony windows called intervertebral foramina.

As a unit, the spinal cord actually ends between the L1 and L2 lumbar vertebrae. The spinal cord then separates into a fine bundle of remaining spinal nerves called the cauda equina, which literally means 'horses hair' because of its resemblance. The far end of the cauda equina is tethered to the tip of the coccyx.

Meninges

The spinal cord is covered by a system of membranes called meninges. The primary function of the meninges is to protect the central nervous system (spinal cord and brain). The meninges are fused to the spinal nerves and end where the spinal nerves begin just outside the intervertebral foramina (see diagram). There are three meningeal layers. The outermost layer is made up of dense fibrous tissue providing a protective barrier. The middle layer cushions the spinal cord and attaches to the inner layer, which is a thin transparent membrane composed of fibrous tissue. The deepest layer firmly adheres to the surface of the spinal cord.

Infection of the meninges, called meningitis, can cause serious neurological damage and even death.

Intervertebral disc

Intervertebral discs (IVDs) are the soft gel-like structures that sit between our vertebrae. The primary functions of the disc are to allow movement between vertebral bodies and to transfer weight from one vertebral body to the next. The disc creates a space between the vertebral bodies — thus permitting the upper vertebra to tilt forwards and backwards without hitting the vertebrae above or beneath it.

The intervertebral disc has two major parts. There is a central 'ball bearing' part which is made up of a jelly-like substance called the nucleus pulposus. This part transfers loads from one disc to the next and allows movement between vertebrae. The second part of the disc is called the annulus fibrosis, which consists of several concentric rings which contain the nucleus in a central position. The nuclear material is toxic to the body if it escapes from the disc and can cause an inflammatory reaction resulting in pain.

Then there are fibrous concentric rings called lamellae that prevent the jelly-like matter from entering the rest of the body.

With age, the intervertebral discs slowly dehydrate to approximately 70 per cent by the age of 60. Optimally, the intervertebral disc resists spinal compression while permitting limited movements. Together, the nucleus and annulus distribute loads across the vertebral bodies even when the spine is bent, flexed or extended. A third component of the disc is the vertebral endplate. Each disc has two endplates, which are layers of cartilage that cover the top and bottom aspects of each disc.

Pain-sensitive nerve fibres normally penetrate only the outermost part of the disc. Therefore, you only experience pain from the disc if you injure its outermost part. Certain injuries can permanently alter the structure and function of a disc. However, this does not mean that the disc will be forever painful. In this book we will explore rehabilitation options that are open to sufferers of such injuries.

Discs are thickest in the lumbar region as they are required to bear greater loads, and are thinnest in the upper thoracic region.

Intervertebral discs are the largest structures in the human body that have no direct blood supply. Nutrients are transported into the disc via blood diffused into the disc from the vertebrae above and below. The pumping of blood occurs thanks to movement of the spine. Conversely, recurrent unloading of the spine allows waste products from the disc to be sucked back into the vertebral body to return to blood circulation.

Annulus fibrosus

The annulus fibrosus is the outer part of the disc, making up approximately half the diameter of the disc. It is comprised of concentric rings of fibrocartilage called lamellae that do not fully encircle the nucleus.

The posterolateral area of the annulus contains the greatest number of incomplete layers. This is one reason discs in the lumbar spine usually tear in the posterolateral region. These factors make the disc thicker in the front and sides, creating a thinner and slightly weaker back portion of the annulus, predisposing it to degenerative change and trauma. Increased collagen fibres are found in the outer lamellae, providing extra strength in torsion, flexion, extension and lateral flexion movements. This is helpful because more stress falls on the outer lamellae.

Nucleus pulposus

The nucleus pulposus is the inner part of the disc and comprises about half of the disc diameter. It consists of a water gel held together loosely by a network of fibres. The nucleus attracts and retains water, needed to resist spinal compression. In a newborn baby the fluid content of the nucleus accounts for approximately 90 per cent of the weight, while for a 77-year-old it only accounts for 65 per cent of the weight.

Being a semifluid gel, the nucleus can be deformed under pressure without a reduction in volume. Compression of the nucleus causes it to deform and transmit the applied pressure to its surrounding structures — namely, the annulus fibrosus and vertebral endplates. What occurs can be compared to the effect you get if you have a balloon filled with water and you apply pressure to the balloon. The balloon will deform as the pressure inside the balloon rises and stretches the walls of the balloon in all directions. Although disc problems are a common cause of back pain, the nucleus lacks a nerve supply, and thus cannot by itself be the primary source of back pain. The pain in disc sufferers originates in other structures that are compromised by the failure of the nucleus.

Vertebral endplates

Vertebral endplates are thin layers of cartilage about 0.6 to 1 mm thick that cover the top and bottom of the disc.

Vertebral endplates are responsible for the growth in height of the vertebral bodies and prevent the nucleus from bulging into the vertebral body.

When we are born our endplates have many small blood vessels; however, these blood vessels gradually die off during the first 10 — 15 years of life, leaving small, weakened areas which make the vertebral body more susceptible to intravertebral disc prolapses called Schmorl's nodes. These can be seen on X-rays, CT and MRI. They weaken the endplate and may be a precursor to collapse of the endplate and/or disc degeneration.

As mentioned previously, discs do not have a direct blood supply. They depend on the nutrients supplied by the adjacent vertebral bodies, which exchange nutrients and waste products via the endplates by means of diffusion. Endplate permeability decreases with ageing, resulting in diminished transport of nutrients and waste products.

Disc nerve supply

The inner one-third of the disc has no nerve supply. Only the outer one-third, and rarely the outer two-thirds, of the disc has nerves. Therefore, injury or damage to the inner third of the disc goes unnoticed. Injury to the outer third part of the disc will result in what is termed 'discogenic pain'. Typically in the lumbar spine this causes generalised referred low back pain and possible buttock and thigh pain that can extend to the knee. The posterior aspect of the disc is innervated by the sinuvertebral nerve. This nerve is involved in most cases of back pain. One therapy, which we'll discuss later in this book, involves cutting the sinuvertebral nerve.

Facet joints

Facet joints connect adjacent vertebrae together. Each vertebra (except for the top two) has two facet joints — one on the left and one on the right; however, anatomical variations can occur between individuals. Lumbar facet joints contain a joint space, membrane, cartilage surfaces and a fibrous capsule.

There are several structures within the joint capsule. During spinal flexion, the facet joints glide upward some 5 mm to 8 mm, thus exposing the joint cartilage of the facet joint. A tissue pad is understood to act as a protective feature of the facet joint when the cartilage is exposed. There are two 'mini-discs' or menisci per facet joint, which are small discs that sit in between the two articular processes. The purpose of these discs is to lubricate the joint.

The lumbar and sacral multifidii muscles insert or attach into the fibrous capsules. It is believed that the muscle protects the capsule from being caught inside the joint during movements.

The facet joints help movements, resist force and bear weight. As we age the intervertebral discs become narrower, which leads to greater weight bearing on the facet joints. Facet joints are not designed to withstand great loads and it is believed that the extra compression leads to degeneration of the joints.

Regardless of exercise, facet joints naturally degenerate with age. By the age of 60 to 69 years, 89 per cent of the population have facet joint osteoarthrosis. The L4/5 and L5/S1 joints are the most commonly affected. Having facet joint osteoarthrosis is not always associated with low back pain.

Facet joints are covered in a thin layer of cartilage that is strongly held together by a joint capsule (a ligament-like structure that encircles the joint). The capsule has many small nerve endings that are sensitive to movement and pain; these are often reported as a source of low back pain. The good news is that by treating one facet joint you can affect the vertebral segment above and below it as well because they all have the same nerve supply.

Muscles

There are three major types of muscle found in the human body — skeletal, cardiac and smooth muscle. Cardiac muscle is only found in the heart, while smooth muscle is found in arteries, lymph tissue and various organs such as the intestines. The type we are interested in here is called skeletal muscle. Skeletal muscle is under voluntary control, which is good news to those suffering back pain. Skeletal muscle is what we are referring to when we speak of the muscles of the back.

There are several layers of muscles in the back (see diagram). As a general rule the more superficial muscles (top layer) are movers, while the deepest muscles tend to be stabilisers. Some muscles have dual roles as a mover and a stabiliser. The simplistic view that a single muscle is the sole cause of back pain is outdated. Current understanding of human musculoskeletal function and physiology indicates that the most common scenario of back pain involving muscles includes several muscles which contribute to the overall condition in varying degrees. This is good news for those who suffer from back pain, because working on muscle strength and balance is something we can all do. The exercises outlined in this book are a great place to start.

(Continues...)

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Excerpted from Back Pain by Adam Gavine, Rod Bonello, Ian Faulkner. Copyright © 2014 Adam Gavine and Rod Bonello. Excerpted by permission of Allen & Unwin.
All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.
Excerpts are provided by Dial-A-Book Inc. solely for the personal use of visitors to this web site.

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Table of Contents

Contents

Preface by Dr Martin Harvey BSc (Anat), MChiro,
Introduction,
Guide to the rehabilitation exercises,
1 Anatomy,
2 Causes of back pain,
3 Diagnosis of back pain,
4 Treatment,
5 How to choose a good therapist for your back pain,
6 Back pain and the workplace,
7 Dos and don'ts,
Conclusion,
Glossary,
References and additional sources,
Acknowledgements,
About the authors,