Back pain and the 'Degenerative Cascade'

In his groundbreaking book "Managing Low Back Pain" published in 1983, William Kirkaldy-Willis described what still remains the single most brilliant explanation of how back problems begin and worsen over time.  His biggest contribution was to explain how minor injury and back pain can begin a degenerative process that progresses into severe spinal disease and disability later in life.  To explain his findings, Kirkaldy-Willis introduced the theory of the 'Degenerative Cascade' (see FIg. 1-1), to demonstrate how each stage of back pain, dysfunction and degeneration is related to the other.  He also showed that the two major anatomical structures in the back (discs and facet joints) are closely interrelated such that problems in one of these structures will cause problems in the other.  

The 'Degenerative Cascade' of Back Pain

What causes back pain?
Poor posture and inadequate control of spinal stability are the most common causes of facet joint injury or disc injury that will kick off the degenerative cascade. If back pain is left untreated and the degenerative cascade is allowed to progress, your spine will gradually collapse and lose height as described in A 'tall spine' is a healthy spine! 

The take home point
Once your back is injured or painful, do something about it!  It will take some work to correct the problems that are causing your back pain but it is well worth the effort. More recent research has shown why this is so crucial...  In response to back pain or injury it is common for your spinal stabilizers to atrophy or weaken. Weak stabilizers will allow more stress to be placed on the spine thereby causing pain and more atrophy.  This 'Back Pain Cycle' can be hard to break and is the primary reason why back pain is so stubborn and can become chronic for so many people.  It is also why post-injury physical therapy including spinal stabilization exercise is important for treatment and prevention of back pain. Contact a physical therapist to help you with your back pain or try a POSTURE BELT for Back Pain if you want to work on it at home.

Back pain remedy found in a unique book

I love this book: Ageless Spine, Lasting Health: The Open Secret to Pain-Free Living and Comfortable Aging

The essential theory in this wonderful work is that the body functions best when it is naturally aligned in an upright posture.  I couldn't agree more with the author's opinion of why good posture is so important to pain-free living and spine health. 

What the book does exceptionally well is to demonstrate optimal spinal posture through the use of pictures that show people functioning in parts of the world where it is essential to perform manual labor as a way of life.  The author contrasts those pictures of health and vitality to pictures of westerners in rounded and slumped postures and it becomes incredibly obvious why back pain has become so common in our society.  Contact a physical therapist to treat your back pain and correct your posture.  If you want to treat your own back pain, try a POSTURE BELT for Back Pain from ActiveOrtho.

A 'tall spine' is a healthy spine!

Poor posture is a common cause of a progression of spinal problems that start with intermittent back pain early in life.  If you stay in poor postural alignment for prolonged periods of time, pain will often become more prolonged and sometimes permanent. The essential problem is how the discs gradually narrow and degenerate so that there is a significant loss of height in the spine.

Posture Test
Try this right now:  Sit down in a chair looking in a mirror and notice how tall you are. Now sit up as straight as you are able... notice if you became taller, now round you back, noticing if you got shorter.

Remember this simple rule: A TALL SPINE IS A HEALTHY SPINE!  When your spine is shortened through rounding or flattening of your back... your discs are being compressed.

Here's another rule about spinal mechanics, if you keep your back rounded long enough... it will stay that way.  Like my mother said to me on more than one occasion while growing up: "If you keep making a face like that... it will stay that way!"  Well, that is how the spine works, plain and simple.

Sitting has become a 'way of life'
The three postures on the right side of the image above show common results of prolonged poor posture.  The point that I make to my back-pain patients is that thousands of years ago, our ancestors needed to be active, energetic and moving around (not sitting) simply to survive.  Since our backs were designed for upright function, with some bending, squatting, reaching, walking and running mixed in, the spine was certainly not designed for prolonged sitting.  Unfortunately sitting has become a way of life for many people.  Think about how much time you spend sitting... in a single day... eating breakfast, driving to work, at work, at lunch, driving home from work, dinner, watching television...  And for children, its not any better... with video games, email and the internet, some kids spend as much, if not more time sitting than adults do.

Why does my back hurt?
If I only had a dollar for every time I've heard that question...  The funny thing is that the answer is probably simpler than you think.  Poor posture in sitting is the #1 most common cause of back pain for many people, which can progress to worsening conditions such as disc bulging, disc herniation, sciatica, disc degeneration and eventually spinal stenosis.

Can I change my posture to help my back pain?
Visit the link above for an answer to this important question.

Contact a physical therapist to help you with your back problem or try a POSTURE BELT for Back Pain if you want to work on this at home.

What’s better for back pain… spine flexion OR extension?

This is an interesting journal article which adds to the discussion regarding the idea that flexion OR extension is better than the other for the treatment of back pain:  MRI evaluation of lumbar spine flexion and extension

As the journal abstract states: "treatment for lumbar spine pain should be based on the symptomatic response to movement and position rather than biomechanical theory."  So in other words, when it comes to the way our backs work, everyone is different and this suggests that using a SINGLE biomechanical model for the treatment of back pain (i.e. spinal flexion OR extension) is based on flawed thinking.  This concept is central to my back treatment programs where we find out what makes YOUR back less painful and then figure out how to stabilize in this pain free (or less painful) position.  Once you are less painful, then you can learn to move safely and without pain… by developing better control of your dynamic spinal stabilizers.  Furthermore, this is my reasoning for suggesting that patients with back pain wear the POSTURE BELT for back pain from ActiveOrtho, as long as it gives back pain relief. If in fact the belt gives pain relief, I would suggest a treatment program that focuses on stabilizing in a neutral spine posture, particularly during sitting.

Prevent back injuries in children: Remember that they are not simply 'small adults'

When it comes to youth sports participation, parents and coaches often forget that kids bodies work VERY differently than adult bodies.  Children are growing, they have growth plates and their strength, flexibility and coordination often lag behind their growth spurts.  Furthermore, when attempting to 'play through' an injury, children will usually develop abnormal movement patterns that can make pain less noticeable for a time; while creating bad habits that can last a lifetime and lead to further injury.  One of the biggest problems with how we look at young athletes and injuries is that everyone has seen and read about professional athletes pushing through painful injuries to go on to win games or even championships.  Since this 'no pain, no gain' approach seems to work for our elite sports heroes,  parents and coaches allow children, and kids feel the pressure, to push through pain in ways that can lead to lasting injuries.  The other issue at play is the 'organized' nature of youth sports. The point is that 'No pain, no gain' does NOT work!  If a child were not playing in an organized practice or game, they would run, jump and play until they are hurt.  Once they get hurt they will stop playing until it doesn't hurt anymore. This is what nature intended for the normal development of skills and correct movement patterns as well as the proper healing of injuries.

As my pediatric orthopedics professor always said "children are not small adults!" and we need to remember that mantra when deciding what is best for our kids now and most importantly in the future.  In general take the slow and steady approach when letting a kid get back to his or her sport.  If you have any questions about what is best for them, ask a physical therapist for help.

Can I really change my posture?

I had a patient ask me that very question earlier today...

My reply was YES... it's simple... but not easy.

I say this to all of my patients with back pain because changing posture really is a simple process, but there are 3 things that you absolutely MUST do in order to have good posture, and these things are not necessarily EASY to do:

1. Develop good mobility of the spine and skeletal structure. 

2. Improve strength of the muscles that support your spine in good posture.

3. You need to think about it. Consciously reminding yourself to 'sit tall' is a good place to start.

Over time your new posture will become second nature.

Again, like I said... SIMPLE, but not easy.  Contact a physical therapist or try a POSTURE BELT for Back Pain if you are interested in doing the work to change your posture to prevent or treat back pain.

Tightening the Gluteals to Correct Posture... Good or Bad Idea?

Most people would say this is a good idea...

...and most people would be:

a. Incorrect regarding relaxed standing posture 

b. Correct regarding activities where the trunk is bent forward

c. Correct regarding activities where one leg is in front of the other (split stance, lunge, etc.)

The short answer is: It depends... 

Here's the thing... 

In standing it is ideal to have a posture that is relaxed and responsive to your environment. If you gluteals are contracted in standing all the time this will simply not be the case.  I like to bring this up because many experts give this advice (I just watched a youtube video from a 'posture expert' who is recommending tight 'bum' muscles in standing) and based on her advice, I should never let them go...? what about when... 

anyway, getting back to my point: 

1. In normal standing, learn to control your pelvic and lower back region with good deep abdominal control: learn how to do a pelvic tilt without using your butt. 

2. Learn to activate/tighten your gluteals in split stance, 1/2 kneeling or lunging positions (basically when one leg is in front of the other).  Add resistance with bands, cables, dumbbells, etc.

3. Make sure you do a lot of training with a neutral pelvis in functional positions like squat, single leg squat, hip hinging, etc, to train better posture and lumbopelvic control.  

If you have difficulty maintaining a neutral spine with these type of activities, try using the POSTURE BELT for Back Pain from ActiveOrtho.  This product was made to treat back pain and prevent back injuries by correcting posture and improving spine stability. 

Back Pain Exercises: Mobility vs. Stability

Individuals who are experiencing back pain routinely think they need to "stretch out" or "loosen up" to get rid of their pain. In physical therapy terms we say these people are looking for mobility.  Then there is another group of people who think they need to "build up the area" around their lower back with abdominal, back or core strengthening.  In physical therapy terms we say these people are looking for stability. 

Back pain can be tricky to effectively manage because there is merit to both of these approaches depending on your particular situation.  What makes self-treatment of back pain so difficult is the approach that people take is often the opposite of what they need.  Think about it... if you were doing exactly what you needed for your back pain, you wouldn't be in pain anymore! Or at the very least you would be getting better...  right? 

For many, the problem is simply not knowing  how the body should optimally work as an effective system.  The best way to explain optimal body mechanics is to discuss what is now being call the 'Mobility-Stability Pattern' by physical therapists, personal trainers & strength and conditioning specialists.

First noted by Gray Cook, PT and Mike Boyle, the concept proposes that the body works in an alternating pattern of stable segments connected by mobile joints and if this pattern is altered – dysfunction and compensation will occur.

In a nutshell:

1. There are areas of the body that require stability for optimal function. If they become unstable: compensation, dysfunction and pain can result.

2. There are areas of the body that require mobility for optimal function. If they become tight or immobile: compensation, dysfunction and pain can result.

Normal Mobility-Stability Pattern

Stable - Foot          

Mobile - Ankle                      

Stable - Knee                

Mobile - Hip                      

Stable - Low Back (Pelvis/Sacrum/Lumbar Spine)    

Mobile - Upper Back (Thoracic Spine)          

Stable - Shoulder Blade (Scapula)

Mobile - Shoulder (Gleno/Humeral)    

Stable - Elbow                      

Mobile - Wrist                      

If you notice, the low back requires stability and the areas above and below require mobility for optimal body mechanics.  It should be starting to make sense now... this is why either approach to back pain can sometimes work and other times not work.  Keep in mind, we are not saying that the low back should never move and that the hip and thoracic spine can never be too mobile.  Just that the low back should be more stable than the areas around it, for it not to be injured by compensation for nearby tightness. 

Training to develop optimal mobility and stability to treat and prevent back pain can be a challenging endeavor. One product that has been shown to be useful in in this training process to improve spinal stability, body mechanics and posture is the POSTURE BELT™ for Back Pain by ActiveOrtho.

What is the BEST posture?

Here's the thing, human beings were designed for movement.  Hunting, gathering, surviving and they certainly weren't designed to sit for prolonged periods.  I'll go out on a limb here and say that anyone not pulling their weight back in prehistoric times was probably 'voted off the island' pretty fast!

So 'normal' posture should ideally consist of numerous different positions and it is crucial for individuals who are sit for prolonged periods to move and stand frequently throughout the day.  With that said it is generally accepted that good posture helps reduce back pain and there is no time when that is more true than when you are experiencing back pain.

Back Pain: When 'Perfect Posture' Counts
Many people who are experiencing back pain feel less pain when lying down flat on their back... often on the floor. The reason that this is the case is that when lying on the floor the spine is naturally placed in a 'good posture'.  Essentially the head, cervical, thoracic, lumbar and sacral regions of the skeleton are placed in an ideal alignment. Many times people will often feel a complete absence of symptoms in this position, particularly when the knees are bent and the legs are elevated in a 90/90 rest position (see image above).  The magic of this position is that the spinal joints, discs and other soft tissues have the least amount of stress and or pressure placed on them like this.

Back Pain Function: Getting Upright
Going from the 90/90 rest position to sitting or standing without worsening back pain can be problematic for many back pain sufferers.  The problem is that a great deal of muscular control, strength, stability and balance of the core musculature is required to stabilize the spine in the same happy position that was found while lying on the floor.  This is where a physical therapist or a product like the Posture Belt by ActiveOrtho can help.

Developing improved posture that will result in back pain relief and prevent future episodes of back pain takes time and effort.  Do the work now!  Get on the right program today so you too can be back pain-free with better posture!