Bill Fabrocini PT, CSCS

If you are reading this section, you probably have a history of back or neck pain and have many questions. Some of you may also have visited one or several medical professionals who have already discussed the causes of your back or neck pain as well as reviewed your X-rays and MRIs. A discussion of joints, ligaments, muscles, and perhaps even discs may have come up. However, you might just feel that you still don’t get it — “just what are those disc structures anyway, and what the heck are those muscles supposed to do to help my pain?” Don’t worry; you’re not alone. Many professionals who have been in the business a long time still have difficulty understanding how it all fits together, so don’t get discouraged. The purpose of this section is to simplify the anatomy and function of the spine so we can have a similar vocabulary and mutual understanding. The more you know, the more you can do to take an active role in the healing process. The first step is to understand the complexity — or should I say the simplicity — of the spine. Let’s begin!
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    The Vertebral Column

    The spine, or vertebral column, is made up of individual bone segments called vertebrae superimposed, one on top of the other, and spaced apart by small, shock-absorbing, spongelike structures called intervertebral discs. The purpose of the spine is to support the body’s weight, protect the spinal cord, and support two-legged human function in standing, sitting, walking, and all other activities of daily life. I like to think of the spine as a chain or series of building blocks (units if you prefer) stacked in a column. A total of 33 vertebrae form the spine. They are divided into sections based on the curves they form (Figure 1). The four sections are the sacrum and coccyx (tail bone), the lumbar spine (lower back), the thoracic spine (mid and upper back), and the cervical spine (neck). I tend to think of the sacrum and coccyx independently since their individual vertebrae are fused and have no disc-like shock-absorbing structures interspaced between them. The sacrum forms the solid base for the spine, where it intersects with the pelvic bones to form the pelvis, also referred to as the pelvic girdle. This entire complex, made up of very strong bones, is vitally important as the foundation that supports the weight of the upper body and spreads that weight across into the legs.

    Figure 1: diagram of the spine  

    As we observe the lower back (lumbar spine), we can identify the various vertebral segments based on a numbering system. The lumbar spine consists of five movable vertebral segments with the bottom-positioned vertebra numbered (L5). Below L5 sits the first sacral vertebra (S1) and above it sits the next lumbar vertebra (L4), with every sequent vertebra decreasing in number (L4), L3). The vertebrae of the lumbar spine are fairly large, compared to the those of cervical spine, since they are at the bottom of the spinal column and must therefore bear a much greater percentage of body weight and forceful muscle contractions. Their shape allows motion between each segment (Figure 2). These are flexion (forward bending), extension (backward bending), rotation (twisting), and side bending. As we will discuss in future blogs, these motions need to be controlled and limited, especially under loaded conditions, to preserve and protect the fragile structures of the spine (joints, discs, etc.). The entire complex of the lumbar vertebrae and the sacrum constitute what is known as the lumbosacral spine and for reasons just mentioned are the origin of most mechanical low back pain and disability. The sacrum’s attachment to the large pelvic bones on each side is also a source of mechanical back pain via the sacroiliac joints. The underlying theme with both the lumbosacral spine and the sacroiliac joints is that they bear the weight of the upper body and have a propensity to break down with repetitive, poor movements and bad posture. That’s basically what your entire BACKFOREVER program is about. BUT, let’s not jump too far ahead. Let’s stay with our anatomy lesson for now.

    As we move upward from the lower back, we move into the mid and upper back region, termed the thoracic spine. The thoracic spine is made up of 12 units that range from (T12) at the bottom to (T1) at the top. Obviously, (T12) rests on top of the (L1) segment of the lumbar spine. The thoracic vertebrae are more rigid to provide the framework for the rib cage and the torso that protects the vital internal organs. Because they are more rigid, they have fewer mechanical problems than the low back and neck.

    Further upward we arrive in the region of the neck (cervical spine). The cervical spine consists of seven smaller vertebrae ranging from C7 at the bottom to C1 at the top. These vertebral units function to support the weight of the head and are very flexible to allow multidirectional head movements, including rotation and bending. Mechanical neck pain dysfunctions are relatively common because of this role. More on that later.

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    The Vertebrae

    The vertebral units are really two connecting bone segments, with a front and a back that serve different functions (Figure 2). The front segment, termed the body, is essentially a supporting, weight-bearing, flexible structure (with the shock- absorber discs between the levels). The back segment is more of a ring-like, nonweight-bearing structure that forms a hollow space housing and protecting the spinal cord, a vital portion of the central nervous system we need to survive. The back segment also consists of two paired facet joints (Figure 3) that direct motion of the vertebrae, as well as a spiny point (the spinous process) which projects outward beneath the skin. Facet joints, like any other joint have a cartilage surface and are susceptible to wear and tear that may lead to degenerative changes such as arthritis. Additionally, vertebrae attach to ligaments and muscles that connect and anchor them from above and below. Ligaments serve as cable-like structures for support so that the spine stays under a state of tension. There are also numerous muscles that span the spine for further support and keep it erect. These muscles and ligaments are vital to the health, function, and structure of the entire spine. We will discuss this in greater detail in the muscle and ligament section.

    Figure 2:

    vertebrae in neutral position, extension and flexion TIME OUT:

    OK, let’s all take a breath. I know that is a lot to absorb. For now, simply try to get a feel of what the spine looks like and how fragile it can be if not “stacked up” properly. Think of a long, segmented rod with movement between each segment and sitting on a solid base, held upright by cable-like ligament structures and muscles that exert force to hold it in place and control motion between segments. I just went through the “building foundation.” Now for the “electrical wiring.”

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    The Spinal Cord and Peripheral Nerves

    Lets begin with a brief description of your brain, part of the mainframe computer system that runs your entire body. Every electrical signal in your body (billions and billions of them) is processed in the brain. These include signals that relay information about temperature, touch, pain, movement, awareness, digestion, breath, or heart rate. The bundle of nerves that sends these signals to and from the brain constitutes the spinal cord. Think of the spinal cord as a highway of nerves that runs north and south, encased in and protected by the middle of the vertebral column (the spine). The spinal cord, together with the brain, form the central nervous system (CNS). The CNS is vital for every function in your body. Quite simply, the CNS is your life. In addition to the highway of nerves that run through the spine via the spinal cord, numerous exits along the way allows the spinal cord to connect to every body structure. These exits occur at every level of the spine between each vertebral segment and resemble small holes that allow the nerves to pass in and out of the spinal cord. These little holes are termed intervertebral foramina and are specific to each level of the spine, such as between C5 and C6 or L4 and L5. The cervical spine (neck) has exit holes (foramina) to the left and right that provide signals to the arms, while in the lumbar spine the exit holes provide a nerve pathway to the legs. Keep in mind that these exit points also transmit signals to and from every organ in the body including the heart and lungs. The points at which the nerves branch off the spinal cord and exit to the outside of the spine are termed the peripheral nerve roots, which together form the peripheral nervous system (PNS). As we will eventually explore, it is at these exit hole points that so many problems arise, as the peripheral nerve roots are prone to compression and stretching by various spine structures (disc, ligaments, bone spurs). Nerves under constant pressure wreak havoc on our body in many ways. That is one reason why spine health must be maintained — or in most cases, reestablished.

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    The Intervertebral Discs

    Discs probably receive more attention than any other structure in the spine. Most people learn about them in their damaged state — “bulging discs, ruptured discs, herniated discs.” Discs are hydrodynamic, elastic structures spaced between two vertebrae, separating them and acting as shock absorbers. Visually, they look like washers that space the vertebrae apart. Several metaphors describe a disc, such as a tough jelly donut with a gooey inside, surrounded by a tough, fibrous, circular layer on the outside. (Figure 3) The gooey gel inside constitutes the nucleus pulposus, while the fibrous layered collagen sheets that envelop it constitute the annulus. In the next paragraph I will provide greater detail, but it is essential you understand the anatomy and biology to appreciate their important function in the spine.

    The nucleus gel of the disc is a blend of fibers, sugars, and acids. Its purpose is to absorb water and give it a spongelike function. For the gel to maintain its hydrodynamic, water-absorbing function, it must receive nutrients like all other cells in the body. In the early years of life, the gel is provided with nutrients via a blood flow through the vertebral segments above and below. However, in the years of maturity, the vertebral bodies’ growth plates close, cutting off the critical blood supply to the discs. From this point on, the gel matrix can only receive nutrients via a process that involves alternating compression and relaxation. This pump-like effect allows nutrients to flow in and out of the central nucleus matrix from the surrounding annular ring layers and vertebral ends. When the inner gel matrix is hydrated, it functions much like a tire with an internal pressure that separates the outer threads. Think about how important it is for tires to stay inflated to effectively grip the road and how quickly the outer treads wear out when driven on low pressure, especially on curvy roads that require a great deal of turning. When deflated they are sure to pop a flat. The interior disc matrix functions in a similar manner. It requires an internal pressure to spread the collagen fibers of the annulus outward so that those fibers can stay elongated and maintain their tensile strength to absorb shock and separate the vertebrae. Of course, there are other variables that we will cover in the disc pathology section; but that, in a nutshell, is how discs work. Imagine what happens to your discs if they don’t receive the mandatory alternating compression and relaxation, spongelike action that is essential for their health and function. For example, if you sit all day long you do just that by squishing them constantly with no room for decompression. Now imagine you combine excessive sitting and slouching with lots of bending and twisting. You now have a deflated tire that is going to overstretch and possibly tear. Welcome to the world of bulging and herniated discs. Make sense?

    Figure 3: Intervertebral Disc diagram

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    Spine Ligaments

    Ligaments are cable-like structures that connect bone to bone. They are slightly elastic and can stretch just a bit, but not too much, or they lose their stiffness and fail. They also have a positional role (proprioception) in that their nerve endings send signals to the brain when they are stretched, alerting supporting muscle groups to contract to provide additional support to the surrounding joints. They are critical for the structural integrity of every joint in the body. Ligaments are especially important in the spine because of its long, narrow, vertical length and the many movable segments (vertebrae) that must be controlled. Imagine building a skyscraper without support beams connecting the main components. The whole thing would come crashing down. The spine analogy is similar, and every ligament has an important role to keep motion in check. If even one ligament fails, the entire system is compromised, resulting in an imbalance of weight and force that has severe consequences on the spinal structures (discs, joints, other ligaments). Because the spine is capable of moving in multiple directions, it has ligaments that attach to its vertebrae at various levels and angles to give it greater support. For example, thick, strong ligaments run the entire length of the back portion of the vertebrae (posterior longitudinal ligament) and function to keep forward bending in check while the opposite ligament groups on the front side (anterior longitudinal ligament) function to keep backward bending in control (Figure 4). For every direction there is a ligament that functions to keep that movement in check. The most significant point to make about ligaments is that prolonged bad postures and movements can overstretch them to the point they fail. When that happens, the ligament can no longer impart stiffness to its connecting bones, and that disrupts the entire balance of forces across the joint. This is where muscles come in to reestablish support.

    Figure 4: vertebral ligament diagram

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    Core Muscles

    Let’s first establish a definition for the core, since it is often misunderstood and thought of as the midsection and the surrounding abdominal muscles. It is really much more. The core includes the chest, back, and abdomen as well as all of its bone structures including the spine, rib cage, and pelvic and shoulder girdles. It is the link between the upper and lower body including, all of the muscles that span this distance. The core muscles work together as an integrated system, similar to the way musicians complement one another in an orchestra. They are essential to keeping us upright, resisting compression, and supporting our body weight. They provide the framework for postural alignment that is required for every movement, from pushing and pulling to squatting and bending. One of their main jobs is to keep the spine stable and supported so that the powerful hip and leg muscles can directly transfer the force they produce into the shoulders and arms (and vice versa). Visualize a tennis server whose power is initiated by bending the hips and knees, then recoiling quickly upward and transferring force through the core into the shoulders and arms, eventually completing a powerful snap at the wrist. Even the simplest of tasks like walking require that the core muscles work together to complete this energy transfer mechanism. As we look at the core from the front, side, and back, we can break up the muscles into groups, but we always stress that they work together. The degree to which each muscle contracts and imparts stiffness to their corresponding joint(s) will determine the total amount of stability in the spine. Obviously, the core has many muscles groups that are all significant. Let’s look at few of them based on their positions.

    Figure 5: diagram of the body's core muscles

    Muscles on the back: Posterior

    The muscles in the back that run parallel to the spine and produce backward-bending force are referred to as the paraspinals. Basically, they function to extend the spine and protect it from forward-bending forces and movements. Like most muscle groups in the body, they are made up of big, powerful ones and smaller, assisting ones. The smaller ones are the deepest and travel shorter distances, connecting adjacent vertebrae. They provide movement corrections at specific vertebral joints that are under stressful loads, for example when lifting. They are the first responders to movement in the sense that they contract first, as well as provide essential feedback to the bigger muscles as to the position (or change of position) of each vertebral segment. These muscles are essential for the protection and performance of the spine. The bigger extensor muscles are the workers; they produce the force that extends the spine as well as protects it during forward-bending movements. The extensors are made up of several layers that build outward and form the prominent mass of tissue on each side of the spine extending from the sacrum to the skull (Figure 5). As we will discuss in the pathology section, their function to protect and efficiently move the spine depends completely on posture.

    Also worth noting is that the muscles on the back of the neck function in the same manner. Intrinsic paraspinals connect the adjacent cervical vertebrae, providing movement corrections through small adjustments at the joints, especially when the neck is forcefully and suddenly loaded (whiplash, for example).

    Muscles on the front/side: Anterolateral

    On the front and sides of the lower torso, we can observe the muscles that encase the abdominal cavity and form the abdominal wall. (Figure 5) Walk into any gym or Pilates studio and you will find people working on these muscles for that slender midsection look. The abdominal wall consists of layers of criss-crossing muscles; the external obliques, the internal obliques, and the deeper, horizontally oriented transverse abdominis. These muscles have many functions including to flex, side bend, and rotate the torso, assist in forced expiration such as when you cough or sneeze, and also stiffen the spine via connections to the thoracolumbar fascia. Don’t let the long word intimidate you. Basically think of the fascia as dense connective tissue that forms an “abdominal loop,” wrapping around the sides to the back and attaching on the spine (Figure 5). It functions very much like a girdle. As the muscles of the abdominal wall contract, they tighten this girdle and impart stiffness to the spine in an elastic, “Saran Wrap”-like manner. This concept is sometimes referred to as “bracing.” Bracing involves tensing the abdominal wall muscles to take advantage of the body’s natural “back belt.” This is one of the most important things you will soon learn how to do. Bracing allows the core to do its most important job in respect to the spine: stop motion. The core brace prevents motion from occurring in the spine while transferring force to the arms and legs.

    It’s an amazing mechanical system, but like all machines requires maintenance (think exercise!) to keep it functioning well. Perhaps no core muscle gets more attention than the front and centered rectus abdominis, also more commonly known as the abs or “six pack” muscles. The rectus abdominis is a paired muscle running vertically on each side of the front wall of the abdomen, famous for that six or eight pack look (Figure 5). Contracting the abs is typically associated with flexing the torso and spine, such as when crunching. It is also associated with tensing them without movement to increase abdominal cavity pressure during exhalation, defecation, and urination. Just as important, the rectus abdominis muscles function as a vital part of the natural back belt via fascia attachments to the abdominal wall.

    And let’s not forget about the neck. Resembling the lower back, the neck has a similar arrangement of front and lateral supporting muscle groups. They constitute the deep neck flexors that are essential not only for neck flexion and side bending but for posture and stabilization of the cervical spine. More of this to come when we discuss neck injuries and dysfunctions.

    Muscles on the back/side: Posterolateral

    One other muscle viewed from the side and back worth mentioning is the latissimus dorsi or sometimes in they gym referred to as the “lats.” (Figure 5) The lats form that V-looking appearance on our sides and backs (common with swimmers), but more important, they are part of the natural back belt as they originate on the thoracolumbar fascia (Figure 5). Because of their fiber orientation they exert force on an oblique angle, furthering the tension on the fascia and “tightening the belt.” Lats are important, key spine stabilizers that are sometimes forgotten in back rehab programs. You’ll be doing very focused lat exercises in your program. If I have not stated this enough already, the core functions as a unit with all the muscles contributing.

    Pelvic Muscles

    Two particular pelvic muscle groups also have special significance. The first is the gluteals, sometimes called the “glutes.” The glutes consist of three muscles that make up the buttocks (Figures 5,6). They are powerhouses used to absorb shocks absorption and produce propulsion force to overcome gravity. The biggest gluteal muscle, the gluteus maximus, is the most powerful hip extensor, essentially the strongest muscle in the body. The glutes should contract and absorb body weight every time we squat, lift, jump, walk, run, or simply stand. I say should because sometimes they stop doing their jobs. This can lead to all types of musculoskeletal problems both above (spine, shoulder) and below (hip, knee, ankle, foot). What exactly leads to these important, powerful muscles turning off and becoming atrophied? You may have already guessed it: prolonged sitting and bad posture. Sitting, especially while slouching, compresses the nerves and vessels in the buttocks. Over time they basically shut off like a light switch. The problem with this is that the spine must now take on a much greater load that the glutes were specifically designed to bear. In most cases the spine just can’t handle this and it begins to break down. This is especially true when bending over and is one reason why so many people get hurt when lifting things off the floor. Waking up and strengthening the glutes is critical to spine health. Stay tuned!

    Figure 6: gluteus maximus diagram

    The other critical muscle worth mentioning on the front of the pelvis and attaching to the lower back vertebral segments is the psoas (Figure 7). The psoas is a deeply positioned core muscle on each side of the body, connecting the lumbar vertebrae to the femur. It actually shares its function with another muscle, the iliacus (forming the iliopsoas), to flex the hip (as when you lift your knee towards your chest). The problem with the psoas is that it typically shortens and gets tight because of a dominance of daily flexion activities such as prolonged sitting and sleeping in the fetal position. In its shortened or tight state, the psoas increases compression on the lumbar spine. Even worse is when one side is tighter than the other, leading to all types of asymmetrical forces that tug at the spine. The good news is that once flexibility (and often strength) is restored, the psoas can once again function as a critical spine stabilizer.

    Figure 7: diagram of the psoas

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    The Fascia

    Fascia is a sheet-like connective tissue, somewhat like ligaments and tendons, composed of collagen fibers. I like to think of it as the “Saran Wrap” that surrounds all of the organs, muscles, and tissues of the human body. Fascia is very thin and it helps transfer mechanical forces throughout the body from one muscle group to another. It is also important in helping muscles and other tissues glide smoothly over one another. In the spine, the fascia connects the supporting muscles while helping to transfer loads safely. It is loaded with nerve endings that are vital for sensory feedback. Touch, pressure, body position, and other sensations are all conveyed to the brain via the fascia. The fascia can also be a source of back pain, one reason why so many massage therapists stay busy. Rolfing specialists spend hours stretching and manipulating the fascia to improve its mobility and function.

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    Spine Curves (Posture)

    Lastly, we must appreciate the spine with all of its individual vertebral segments is not in fact vertical but made up of curves. When viewed in the erect position these curves constitute the human body posture (Figure 8). As mentioned earlier, the spine has three curves that correspond to the cervical (neck), thoracic (mid back), and lumbar (lower back) spine. The spine curves are developed in the infancy period of life and are influenced through muscle contractions that pull and mold the spine as well as the angular shape of the discs. In a healthy spine the curves bisect our center of gravity and balance each other. They are essential for all aspects of two-legged human function. Because of their arch-like structural design, they impart strength to the spine that helps it overcome the compressive forces of gravity with minimal energy expenditure. From an engineering perspective, the spine functions much like a suspension bridge that is designed to support massive amounts of weight. Unfortunately, the spinal curves are directly impacted by prolonged poor posture and repeated bad movements (YOUR BEHAVIOR!) that can change the angle of the curves, often flattening them out or exaggerating them. The low back and neck are particularly prone to flattening with age as the spine structures wear down from bad positioning. Think about how many years you may have been sitting slouched or texting with your head looking down, or bending over poorly (Figure 8). In these situations the spine ligaments, discs, and joints are all susceptible to overstress and often fail. Muscles turn off and stop doing their jobs and the spine can no longer stay erect and properly absorb shock and load. The entire core unit is compromised and therefore the ability to move efficiently, to overcome gravity without damage, and to do all other functions of human movement decline. It is a perpetual negative feedback loop that corrodes and wears down the body. Fortunately, the reverse is also true. Doing the right things: the right exercises, the right movements in daily life, and the right postures can rebuild the core and take stress off of the spine. That is what you here to learn.

    Figure 8: diagram of different postures, or curves of the spine


Bill Fabrocini PT, CSCS

As you may have realized while reading the Spine Anatomy and Function section, most of the problems that lead to back pain and disability have little to do with typical diseases. That is not to say that cancer, organ failure, diabetes, and a host of other diseases are not the origin of back pain. They can be, but they account for the minority of spine problems. By far, the majority of troubles spanning from the neck to the lower back are mechanical and directly related to BEHAVIOR. By behavior I mean the way you carry yourself and the repetitive and sustained stresses of daily life and/or sports. When these stresses occur in a frequency and at a threshold beyond that which the spine can tolerate, the result is microtrauma to its soft tissue structures (discs, ligaments, cartilage). Weakening of these soft tissues that function to hold and connect the spine bones further weaken it and lead to more and more problems. We spent a great deal of time reviewing these structures and their vital roles in the Spine Anatomy and Function section. If you have not read this section, I recommend you start there first.

Take note of the following as you read: For most of the conditions listed below, behavioral change and exercise are the best treatment options out there. That is what you are here to learn at BACKFOREVER. Let’s now move on and discuss some of the most common spine dysfunctions and how they occur.

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    Disc Protrusion

    If you recall, discs are shock absorbers located between the vertebrae that cushion the spine and contribute to its flexibility. They are a typical source of back pain and perhaps more than any other spine structure are susceptible to the wear and tear of daily life. A disc protrusion is a degenerative condition in which the discs central inner gel material (nucleus) is displaced in a specific direction and location within the disc. In other words, the inner disc gel leaks. This forms a bulge in the outer ring (annulus) layers of the disc (Figure 1). The terms disc protrusion and bulge are used interchangeably. Because the outer disc ring layers are loaded with sensory nerve endings, they become a source of pain when they are overly stretched, causing the pain that occurs with a bulge. The outer ring stretches but does not tear or rupture. Severity of symptoms can vary and depend on which levels of the spine are affected (neck, mid, or lower back) and the size of the bulge. They range from generalized stiffness and spasms, especially in the morning or after prolonged sitting, to localized neck or low back pain. In instances where the bulge is large enough to encroach into the spinal canal or foramina (nerve exit holes) they may compress or irritate the peripheral nerve roots. Symptoms can progress to include radiating pain down the arm or leg (sciatica), numbness and tingling in the limbs, and in extreme conditions muscle weakness. Muscle weakness in the legs and foot may cause stumbling, and in the arms and hands it may result in an impairment of gripping and pushing ability.

    Figure 1: pinched nerve and disc bulge

    Disc protrusions are often the result of the accumulated effects of months or even years of poor spine alignment, typical with flexion (forward bending) postures associated with slouched sitting, bending over, and/or lifting while twisting. Such positions cause the disc to incur uneven pressures that displace its inner gel backwards toward the spinal cord. As mentioned earlier, this stretches the outer annular ring layer causing it to weaken and deform, potentially compressing and irritating the exiting nerve roots (Figure 1). If postural and movement corrections are not addressed (this is what we teach you in your BACKFOREVER program) the condition can worsen to the next level of disc displacement, called a herniation.

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    Disc Herniation

    A herniation occurs when the disc’s outer ring layers rupture, causing the contents of the inner gel and fragments to extrude outward into the spinal canal (Figure 2). As mentioned earlier, herniated discs often begin as bulges that gradually wear down and weaken until the outer wall tears. Herniated discs are synonymous with the layman’s term slipped disc, although the term is somewhat misleading in that the entire disc does not rupture or slip out of position. Only a small area of the outer ring cracks, allowing fragments of disc material to escape through the tear. When the contents of the disc spill over into the spinal cord, they can then migrate into other locations including the exiting peripheral nerve roots. These nerve roots exit through small holes (foramina) that get even smaller when they are filled with the disc fragments. The resulting pressure created on the nerve root constitutes a nerve impingement or what is more commonly called a pinched nerve (Figure 2). Nerves do not tolerate compression very well, and if the pressure becomes too great or is sustained for too long they will eventually be damaged. Symptoms of nerve damage include sensations down the arms or legs such as radiating pain, tingling, numbness, and muscle weakness. Pain can also be intensified as the nerve root is exposed to the toxic acid contents of the discs inner gel as well as the inflammatory chemicals produced by the damaged disc.

    Figure 2: herniated disc

    Disc herniation requires medical intervention and is confirmed with diagnostic testing such as MRI. Treatment approaches should focus on reducing nerve and disc symptoms primarily through postural and movement reeducation. Other treatments include corrective exercises, medication, steroids, spinal injections, physical therapy modalities (ie, electrical stimulation and ice), acupuncture, and massage. Nerves heal slowly, so time, a wait-and-see approach, and constant reevaluation of symptoms are required. However, if there are immediate or progressing signs of advanced nerve damage (severe muscle weakness, bladder and bowel dysfunction) surgical intervention is indicated.

    As with disc protrusions, the best approach is prevention. Good posture and movements, weight management and fitness, and learning proper exercises to stabilize the core, will reduce the incidence of disc trauma disorders.

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    Spondylosis (Spine Arthritis)

    Spondylosis, also known as spinal osteoarthritis, is a general term to describe degenerative conditions of the spine. Similar to arthritis in aging knees or hips, the spine with all its joints, cartilage, ligaments, and bones can wear down, resulting in chronic pain and stiffness. It can occur in any region of the spine but is most common in the neck and lower back. Flattening of the spinal curves and decreased mobility are common. It can affect a person at any age, but the incidence increases with age. Pain can vary greatly from person to person and can occur after periods of prolonged inactivity or during times of high activity. Symptoms such as intensified pain when moving the spine in a particular direction (flexing or extending) give clues to the spinal structures affected as well as the severity of the deterioration. Spondylosis is influenced by any condition that places excessive pressure on the spine. Listed below are a few common causes that can accelerate its progression.

    • Poor posture (slouching)
    • Bad body mechanics in daily living (rounding the lower back when lifting)
    • Bad body mechanics in sports (high-velocity twisting the lower spine; golf or tennis)
    • Injuries that damage ligaments (whiplash)
    • Overweight, poor nutrition, excessive alcohol
    • Genetic spine abnormalities
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    Degenerative Disc Disease/ Facet Joint Syndrome

    Spondylosis (spine arthritis) is a degenerative condition that can also affect the intervertebral discs and facet joints. When the discs are affected the process is referred to as degenerative disc disease. If you recall from the anatomy section, discs are elastic, spongelike structures spaced between two vertebrae and function as shock absorbers. As people age, the forces of gravity and muscle contractions continue to press the vertebrae together and compress the discs. Years and years of pressure dehydrate the discs and they begin to shrink and wear down (Figure 3). In this degenerative condition the discs’ ability to absorb shock is compromised. Unfortunately, when one part of the spine deteriorates, it directly affects other nearby regions. Hence, as you lose disc height and function, the vertebral facet joints take on more of your body weight. Because these joints are constantly involved with spine motion, they commonly wear down, especially when they begin to take on additional body weight loads that were once the job of the discs.

    Facet joint syndrome, otherwise known as facet joint osteoarthritis (Figure 4) occurs when the cartilage joint surface wears down and reactive bone formation begins to produce an overgrowth of bone spurs (osteophytes) (Figure 3) and an enlargement of the joint. These structural changes, as well as the arthritis-induced joint inflammation, often result in pain with spine motion. The neck and low back are the most areas often affected because of their larger ranges of motion. Symptoms in the neck include pain and stiffness, headaches, and referred pain into the shoulder girdle. People affected in the lower back may experience pain and stiffness, referred pain to the buttocks and thighs, and pain with movements, especially attempting to stand up straight. Reflex muscle spasms further add to the pain and can cause all types of contorted spine positions, including tilts to one side or the other. It’s a perpetual negative cycle.

    Figure 3: disc shrinking and wearing down Figure 4: facet joint osteoarthritis

    Treatment approaches are generally conservative and range from anti-inflammatory medications, spinal injections, ice and heat, and rest. Physical therapy, chiropractic care, and other professional services are also viable forms of treatment. Like all arthritic conditions, facet joint syndrome and degenerative disc disease are natural parts of aging. However, the severity and progression of the disease are directly influenced by years, often decades, of excessive compressive force that we allow our spines to tolerate. In other words, we directly determine the amount of pressure on our spines based upon the manner in which we choose to organize its alignment, that is, posture. Never underestimate the power of good posture, as well as core stability and refined movement, to dissipate loads on the spine. Even in conditions of advanced spine arthritis, these interventions can often improve and sometimes completely restore function. For the person suffering from the pain and disability of spine arthritis, it may make all the difference in the world.

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    Foraminal Stenosis

    Foramina are the small passages between vertebrae that allow for spinal nerves to exit the spine. Degenerative conditions, the combination of decreased disc height, facet joint bone spurs, and large disc bulges or ligament thickening can all encroach in between the vertebrae and narrow this precious space. When these passages become narrowed or obstructed, they can compress and pinch on the spinal nerve, a condition referred to as foraminal stenosis (Figure 5). This often results in neck or lower back pain and stiffness, as well as symptoms associated with nerve irritation. These symptoms vary depending on the severity of nerve compression and the location of the stenosis.

    The lower back is the most typical area of stenosis and can affect several lumbar nerves. The large sciatic nerve that exits between the lower lumbar vertebrae is especially vulnerable and when irritated produces symptoms of sciatica. Sciatica symptoms include tingling, numbness, and pain that radiate along the course of the nerve from the lower back into the buttocks and back of the legs. Typically only one side of the body is affected. The neck is also a common location of stenosis and affects nerve roots that exit the cervical spine. Neck pain and stiffness accompanied by symptoms of nerve irritation may produce tingling, numbness, and pain radiating into the arm and hand. In severe conditions, muscle weakness can occur that may impact the ability to grip objects or use the arms. Symptoms vary depending on which cervical nerves are affected.

    Figure 5: foraminal stenosis

    Treatment for foraminal stenosis must first focus on education. People suffering from this disorder must learn how to avoid the positions and movements that irritate and aggravate their condition. This may entail avoiding extension (back-bending) of the cervical or lumbar spine, as when looking up from the neck or arching the low back while standing or lying on your back with knees straightened. A detailed prescription exercise program that teaches people how to decompress the spine joints and nerve roots will serve them well. Other treatments include medication, steroids, ice and heat, electrical stimulation, weight management, massage, and alternative medicine approaches such as acupuncture.

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    Central Canal Stenosis

    Central canal stenosis is another type of spinal stenosis that refers to the narrowing of the spinal canal, that part of the spine that encloses and protects the fragile spinal cord (Figure 6). Similar to foraminal stenosis, it is usually the result of degenerative changes that structurally weaken and deform the components of the spine. Shrinking discs, disc bulges, disc herniations, bone spurs, and thickened ligaments can all narrow the spinal canal and compress the spinal cord. Additional causes include tumors, bony overgrowth, and spinal injuries that can fracture and dislocate the vertebrae. Central canal stenosis is more common in the aging population, especially those over the age of 50 who have more wear and tear on their spine. Some people may not show any symptoms, while others will experience tingling, numbness, pain, and muscle weakness. Generally the condition worsens with age.

    Central canal stenosis is classified based on its location. The most common area is the lumbar spine, defined as lumbar stenosis. Symptoms can vary greatly and may include lower back pain, numbness or tingling in the leg and foot, and muscle weakness. In more advanced cases, leg cramping or pain can make walking and standing difficult. Contrarily, forward-bending or sitting will provide relief. That’s why older people with advanced stenosis often walk with the assistance of a cane or walker in a bent-over, slouched posture. Central canal stenosis is also common in the neck (cervical stenosis). Symptoms may include neck pain, numbness or tingling in the arms or hand, and muscle weakness affecting the ability to grip objects or lift the arms. This form of stenosis can also potentially cause problems distally into both legs. Muscle weakness, poor balance, and difficulty walking can occur. In the most extreme conditions, bowel and bladder dysfunction, as well as the potential for paralysis, can occur, requiring immediate surgical intervention.

    Figure 6: narrowing of the spinal canal and bone spurs

    Diagnosis of spinal stenosis requires a thorough medical neurological examination. Special diagnostic testing such as X-ray and MRI may also be indicated. Treatment approaches vary depending on the severity of spinal cord encroachment. Moderate cases usually implement a conservative treatment approach similar to that for foraminal stenosis: postural education, exercises, medication, ice and heat, and massage may yield the best results. In more severe cases, surgery maybe necessary to decompress the spinal cord.

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    Spondylolisthesis is a spine disorder in which one bone (vertebra) in your spine slips forward relative to another below it (Figure 7). The disorder is often associated with a congenital weakness that manifests as a stress fracture in the vertebra. In older adults it can occur in the form of degeneration due to arthritic joint changes while in younger adults it is more associated with direct trauma or injury to the vertebra. The most common site for occurrence is the lumbosacral joint (L5S1), with diagnosis confirmed by X-rays. Many people may have spondylolisthesis without signs or symptoms. Symptoms usually occur only if the vertebral segment becomes unstable and aggravated by the stress of excessive movement and activity. If the forward displacement is great enough, there may be narrowing of the spinal cord (central canal stenosis) or compression of the nerve roots (foraminal stenosis). Symptoms can include lower back or leg pain, hamstring tightness, and numbness and tingling in the legs. People will often present with an increased lumbar lordosis (low back arch) and complain that prolonged standing or activity increases the pain while sitting relieves it. The increased lumbar lordosis is significant in that this posture greatly exaggerates the forces that cause the two segments to slip apart. Children and teenagers engaged in sports requiring excessive lumbar lordosis (gymnastics) and contract sports are  more at risk to develop spondylolisthesis.

    Figure 7: Spondylolisthesis

    Treatment for spondylolisthesis is centered around postural education and abdominal and gluteal strengthening exercises, as well as other flexion exercises that reduce the lumbar lordosis. Bracing and lumbosacral supports are also sometimes necessary, as well as rest and modification of activity. If conservative treatment is unsuccessful, surgery is sometimes necessary.

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    Lumbar Strain or Sprain

    A lumbar strain (Figure 8) occurs when one or more of the spine muscles (or tendons) tear because of excessive tension or stretch. Muscle strains are sometimes referred to as a pull or tear but they all describe muscle fiber and/or tendon damage. Muscle strains can range in severity from mild overstretching of the fibers to partial tearing, and in extreme conditions, complete rupture. The person who suffers a mild strain will usually describe an ache or tightness at the injury site, while in more severe case it is a sudden, sharper, searing sensation. Recovery can take anywhere from a few days to a few weeks; however, full recovery of muscle strength and function can take much longer. Several situations that can overload the spine muscles, leading to a back or neck strain:

    • Sudden, quick movements that may happen in sports, unexpected slips or falls, car accidents (whiplash), or forceful coughing
    • Heavy loads imposed on the spine such as when strenuous lifting
    • Repetitive stressful movements (shoveling snow)
    • Overuse and fatigue due to lack of recovery from strenuous work or exercise.
    • Poor muscle coordination and atrophy associated with deconditioning

    Figure 8: muscle strain of lower back

    Many of these injuries appear to happen in a one time, specific traumatic instance; however, a longer history of muscle weakness and/or tightness is typical and a common denominator in many acute injuries. Poor posture and improper body mechanics with movement are especially prevalent and often lead to muscle weakness and imbalances that make one prone to back strains. Regardless of the mechanism, spine strains can result in pain and soreness, tightness, and weakness. Ultimately muscle function is compromised, with an inability to effectively support and stabilize the spine. Additional injuries to other spine structures (ligaments, discs) may occur if proper muscle function is not restored. An integrative approach that addresses rehabilitating the specific injured muscle(s) as well as the supporting core muscles is necessary to optimize function and prevent future injuries.

    A ligament sprain (Figure 9) is the equivalent to a muscle strain. A sprain occurs when ligaments are overstretched and tear. As in muscles,  the severity of injury occurs over a broad range. Mild sprains cause only minimal overstretching and damage to the ligament while moderate sprains cause partial tearing and loosening of the ligament. Mild sprains, classified as grade 1, heal over a couple of weeks, while moderate sprains (grade 2) may require several weeks. In severe sprains (grade 3), the ligament can completely tear, causing extensive joint instability that may require surgery to repair.

    Figure 9:lumbar sprain

    Back and neck sprains resulting in damage to the spine ligaments follow a path similar to that of muscle strains. Both can be the result of sudden traumatic injury or gradual overuse. Poor posture and repetitive movements with bad body mechanics (bending and twisting) are contributing factors. Symptoms are dependent on the degree of injury and can include pain that worsens with movement, muscle guarding, stiffness, limited joint mobility, instability, muscle weakness, and decreased function. Diagnosis is determined by medical examination and entails questions about symptoms and mechanism of injury, touch (pressure) to the injury sites, and assessment of movement and range of motion. In more severe cases, X-rays and MRI may be necessary to rule out additional injury such as fractures. Treatment for back and neck sprains requires modifying activities to allow healing. In more extreme traumatic injuries, immobilization is necessary to protect the ligaments and joints. For example, whiplash injuries (Figure 10) that cause extensive damage to the cervical spine ligaments often require using a cervical collar for several weeks. After some healing has taken place over time, postural education and strengthening and stabilization exercises are also essential to reduce ligament stress and enhance joint support. Modalities and manual therapy techniques including ice, soft tissue mobilization, neuromuscular reeducation, trigger point therapy, are also helpful to restore spine range of motion and function.

    Figure 10:whiplash injuries

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    Piriformis Syndrome

    Piriformis Syndrome is a controversial diagnosis in which the piriformis muscle, located deep in the buttocks, is thought to spasm, resulting in pressure on the underlying sciatic nerve (FIgure 11). The irritated sciatic nerve then causes radiating pain, numbness, and/or tingling along its distribution in the back the leg (sciatica like). Medical professionals still disagree whether the piriformis actually entraps the sciatic nerve and how it occurs. In 15% of the population the sciatic nerve actually pierces through the piriformis and may become entrapped if the muscle spasms. Muscle deviations that cause the piriformis to enlarge or fibrose because of  trauma (falling and landing on the buttocks) can also potentially compress the nerve. The disorder is also sometimes called wallet sciatica, alluding to prolonged external pressure on the nerve as a source. Other causes may relate to leg length discrepancy, pelvic disorders, and hip pathologies that cause the piriformis to reflexively spasm. Some speculate it may have an exercise overuse component such as frequent running or overstretching.

    Piriformis syndrome is controversial because there is a lack of valid scientific tests to support the clinical findings. Clinical tests involve positioning the hip to stretch the piriformis (bringing the knee up across the body) and compress the sciatic nerve. The test is deemed positive if it reproduces the symptoms. Treatment focus is on reducing the spasm through stretching, cold and heat, soft tissue techniques (massage), acupuncture, trigger point therapy, steroid injections, and medication. Because the disorder is vague, perhaps the best approach is to treat what is seen. If the hip joint is tight in certain movement ranges (flexion, extension, rotation), it should be stretched to address those limitations. Similarly, if the hip is weak it should be strengthened, as should the pelvic muscles (gluteals, abdominals). Generally, the body will correct itself if the imbalances are addressed.

    Figure 11:Piriformis Syndrome

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    Ankylosing Spondylitis

    Ankylosing spondylitis is a form of inflammatory arthritis that affects the spine. It is characterized by progressive inflammation that over time can cause some of the vertebrae in the spine to fuse. It usually begins in the sacroiliac joints and later spreads to the lumbar and thoracic spine and ribs. In more advanced cases it can involve the hips and cervical spine. The disease causes ossification of the joints and ligaments, leading to a less mobile spine and a rounded, hunched-over posture that can make breathing difficult. The disease typically occurs in younger adults and begins with symptoms of lower back pain and stiffness that are worse in the morning after getting out of bed and are relieved by movement and exercise. The symptoms can intensity or stop over time, following an intermittent off-and-on pattern. Generally the younger the age of onset, the worse the prognosis.

    Men are affected more often than women.

    Treatment focus is on postural education and exercises to slow the progression of the disease. Massage, stretching, and mobilization may be effective to maintain both spine and hip extension flexibility. Ergonomic supports such as lumbar rolls will further reinforce good spine extension and help maintain the lumbar lordosis when sitting. Medication to control pain and stiffness may be necessary during acute episodes.

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    Rheumatoid Arthritis

    Rheumatoid arthritis (RA) is an autoimmune disorder that causes chronic inflammation and pain in the joints and other body systems. It affects more than two million American people and is more common in women. It typically occurs between the ages of 40 and 60. The disease is characterized by a defect in the body’s own immune system that causes it to attack its own joints. Symptoms usually begin in the distal smaller joints of the body such as the fingers and toes, and over time may progress centrally to the wrist, ankles, elbows, knees, shoulders, and hips. In more extreme cases deformation can occur as ligaments and tendons weaken and lose their ability to hold joint alignment. In addition to inflammation and pain, some people may experience chronic fatigue and a slight fever. The chronic inflammation may also cause damage to the heart, lungs, kidneys, skin, nerves, blood vessels, eyes, and other tissues and organs. Symptoms are often intermittent with flare-ups that come and go.

    There is no cure for RA, but effective drug treatments are available to relieve symptoms and slow the progression of joint damage. Education about health and lifestyle factors is helpful as well as instruction on exercises that will improve joint support. Proper care will involve a team of professionals including rheumatologists, primary physicians, physical and occupational therapists, and nutritionists.

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    Psoriatic Arthritis

    Psoriatic arthritis is another type of autoimmune disease that causes chronic inflammation of the skin (psoriasis) and joints (psoriatic arthritis). The disease may begin with the skin (red, patchy, scaling areas) long before it affects the joints. When the disease impacts the spine, it can cause mild to severe low back pain and stiffness. Additional body symptoms are common and include fatigue, swollen joints, foot pain, and conjunctivitis. Generally the condition worsens over time but may be intermittent, with the symptoms coming and going. If left untreated, the disease can cause severe joint damage. Psoriasis of the skin is treated independently of the joint inflammation. Psoriatic arthritis has no cure, so the focus is on managing symptoms. Similar to rheumatoid arthritis, treatments include medication, ice and heat, physical therapy modalities, manual therapy, and exercise.

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    Compression Fractures

    Compression fractures occur when a part of a vertebra collapses. They are most common in the lumbar and lower, mid thoracic portion of the spine. Typically they occur as fractures in the front portion of the vertebra, causing the front end to collapse and the bone to acquire a wedge shape. More than one vertebra may be fractured in a single incident or over time. Traumatic incidents such as falling and landing on the buttocks can result in a compression fracture, but in most cases the bone is already weakened. The majority of compression fractures occur in geriatric females and are associated with osteoporosis. If the onset of the fracture is progressive, over time there may be only minimal pain and discomfort, while traumatic induced compression fractures (falling) can be quite painful. In more severe cases the fracture may affect the spine and nerve root roots causing pain, tingling, or numbness in the legs or arms. A loss of height with time is also possible.

    Diagnosis of compression fractures is confirmed with diagnostic testing procedures including X-rays, MRI, and CT scan. Surgery is rarely required unless the fracture is unstable. Treatment is usually conservative and includes rest, modification of activity, and medication to relieve pain. Bracing is also effective and often necessary to keep the injured part of the spine in extension to prevent any flexion. This will keep front part of the vertebra spaced apart and allow for healing with as much height as possible. Some gentle, active extension exercises are also recommended to avoid muscle atrophy, which is often a consequence of long-term spinal bracing. In cases in which the cause of the fracture is osteoporosis-related, treatment may also include calcium and Vitamin D supplements. Muscle strengthening, including weight-bearing exercise, core stabilization, movement training, and postural education are the optimal long-term and prevention approach.

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    Bone is a form of connective tissue that provides the major structural and supportive framework of our skeleton. It is composed of cells that are in a constant state of breaking down, being replaced, and building up. When the breaking down process surpasses that of the creation of new bone cells, the imbalance results in a loss bone density, also known as osteoporosis. Osteoporosis is a bone disease that causes the bones to become progressively weaker and so brittle that a gentle fall or sudden movement such as cough can cause a fracture. Osteoporosis affects millions of people, both men and women. The highest-risk population is white and Asian postmenopausal women. This is attributed to the estrogen level drop that directly accelerates the loss of bone density, a condition referred to as postmenopausal osteoporosis.

    Those suffering from osteoporosis will often show no symptoms until the bone fractures. The most common sites are the hip, wrist, and spine. Fall-caused hip fractures in the elderly population can be especially serious and disabling, with an increased risk of death within a year from secondary complications. Spine fractures resulting from osteoporosis occur most often as compression fractures. They frequently involve the thoracic and lumbar spine. Medical attention is necessary when signs reveal a slouched posture, progressive loss in height, and back pain, especially when intensified with forward bending. Compression fractures of the spine often require bracing as well as postural education and exercises to strengthen the spinal extensors.

    Risk factors associated with osteoporosis include genetics, family history, female gender, race, age, calcium and vitamin D deficiencies, poor nutrition, digestion absorption disorders, hormone deficiencies (testosterone or estrogen), long-term corticosteroid use, cancer, early menopause, excessive alcohol, lack of weight-bearing exercises, lupus, and rheumatoid arthritis. Diagnosis is confirmed with routine X-rays as well as more advanced X-rays scans (DXA). Treatment addresses lifestyle changes, especially if alcohol, smoking, and lack of activity are causes. Medications maybe prescribed to address underlying pathologies including hormone deficiencies and autoimmune disorders, as well as medications that increase bone strength and formation. Good nutrition and eating habits, calcium and Vitamin D supplementation, and a professionally guided exercise program are also beneficial. As with most diseases, a cohesive team of professionals (MDs, physical therapists, nutritionists, trainers) serves the client well.

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    Scoliosis is an abnormal posture condition in which the spine rotates and curves to the right or left side (Figure 12). Signs of scoliosis include uneven leg lengths, one shoulder higher than the other, leaning to one side and an asymmetrical ribcage (rib hump). It typically occurs in the thoracic and lumbar spine and begins in adolescence during the growth-spurt years just before puberty. The cause of this alignment abnormality is unknown. Most often the scoliosis is mild and will plateau or correct itself during the growth process, but in more severe cases the spine curvature can progress. Intervention in the form of bracing and an aggressive physical therapy exercise program is necessary. If the curvature continues to worsen, the skeletal structure can become compromised, causing the rib cage to compress against the lungs and heart. Breathing may become more difficult. Surgery is rare but may be advocated in extreme conditions. Routine medical checkups consisting of physical examination and X-rays to measure the curvature are required until skeletal maturity is reached.

    Adults who developed scoliosis as children are more likely to have chronic back pain because of the prolonged structural stress created by the lateral curvature. The shortened concave side incurs greater loads, causing the joints and soft tissue structures on that side of the curve to become compressed. An aggressive exercise program can be effective to lengthen and strengthen the spine musculature to overcome such stresses and control symptoms.

    Not to be confused with pure structural scoliosis as described above are functional scoliosis conditions that are not caused by defects in the bony structure of the spine. A functional scoliosis can occur as the result of other spine dysfunctions. Examples include facet joint impingement, disc bulges, or herniations in which severe muscles spasms cause the spine to shift to the right or left side. This “lateral shift” has a protective function to uncompress the injured soft tissue structures (disc, joint capsule) and is therefore referred to as a protective scoliosis. As the injured tissue heals and muscle spasms subside, the lateral shift resolves itself and the spine straightens. Other causes of functional scoliosis include leg length discrepancies, muscle imbalances, and poor posture. Such conditions can be effectively addressed with a corrective exercise program.

    Figure 12:diagram of Scoliosis

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    Failed Back Surgery Syndrome

    Failed back surgery syndrome (FBSS) is a term to describe clients who continue to experience pain after spine surgery. Spine surgery is performed for several reasons: to stabilize joints), to decompress nerves, to remove soft tissues that are irritating other structures, and so on. Some surgeries have a greater correlation with removal of pain than others. Relief of nerve pain down a leg or arm has a high correlation to the removal of structures compressing on the nerve (discectomy); however, there is less correlation to diminished back pain. Multiple anatomical pathologies may be the cause of low back pain (disc, facet joint, sacroiliac joint), and unless the proper lesion is identified prior to surgery it will continue to be a source of pain afterward. Pain may also persist from complications of the surgery, for example scar tissue formation, failed fusions, postoperative nerve damage, or recurrences of spine conditions such as disc herniations. Typically, if the underlying habits and behaviors that caused the spine issues are not addressed after surgery, pain is likely to return. FBSS can be very frustrating for both the client and surgeon and requires greater introspection to identify the potential cause of pain. Physical therapy modalities including electrical stimulation, nerve blocks, and steroid injections may also be helpful in some cases.

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    Sacroiliac (SI) Joint Dysfunction

    The sacroiliac (SI) joint (Figure 13) connects the sacrum to the pelvic bones on each side of the lower back. The SI joint is movable, consists of cartilage that lines its bony surface, is supported by a network of ligaments and muscles, and like other joints is affected by mechanical stresses that can alter its movement. SI joint disorder, also called SI joint dysfunction or disease, refers to pain that originates from this joint because of abnormal motion. Abnormal motion occurs in the form of too much motion that moves the joint beyond its normal range, or too little motion in which the joint becomes tight and restricted. SI joint dysfunction often leads to inflammation of one or both SI joints, a condition called sacroiliitis. The inflammation may occur acutely from injury or gradually over time from wear and tear (degenerative arthritis). In both instances sacroiliitis can be quite painful and debilitating.

    Figure 13: sacroiliac (SI) joint dysfunction diagram

    Hypermobility is a term that describes too much joint motion. Hypermobility of the SI joint occurs when its supporting ligament are damaged, usually the result of impact injuries such as automobile accidents and traumatic falls. In other cases the damage is more gradual and prolonged. Muscle imbalances and structural asymmetries such as leg length differences or scoliosis can predispose the SI joint to damage under conditions of repetitive mechanical stress (running). Hormone imbalances can also play a role especially those released during pregnancy that result in ligament laxity. In each of these conditions, the SI ligaments stretch and weaken to the point where they can no longer effectively support the joint. As the SI joint becomes loose and unstable, it can frequently “sublux” or get stuck in a misaligned, rotated position, causing debilitating pain. These abnormal joint mechanics predispose the SI joint to premature wear and tear (osteoarthritis).

    Hypomobility of the SI joint is the opposite extreme in which dysfunction occurs because of too little motion or locking. Wear and tear from osteoarthritis or other diseases including rheumatoid arthritis or ankylosing spondylitis can be contributing factors.

    SI joint dysfunction symptoms include lower back pain, buttock pain, and hip pain that can refer to the groin. Sedentary activities associated with prolonged sitting or standing may produce a deep, dull ache that intensifies with activity. Standing up, bending over, going up stairs, walking hills, may further aggravate symptoms. Additionally, SI dysfunction can lead to a host of other musculoskeletal problems with their own set of symptoms. Tightness of the erector spinae, hamstrings, hip flexors, ITB, and several other large muscle groups can intensify pain and dysfunction. Piriformis syndrome in which the piriformis muscle spasms and entraps the sciatic nerve, causing sciatica-like symptoms down the leg is also associated with SI joint dysfunction. Because SI joint dysfunction is often present with lower back and hip joint problems, the diagnosis and treatment are quite challenging. Diagnostic testing with X-rays, CT-scan, or MRI are often negative and not effective to diagnose the dysfunction. Clinical evaluation consisting of applying pressure to tender areas associated with the joint, as well as provocative tests that stress the joint and reproduce the pain patterns, are more reliable. The standard for diagnosis is SI injection with local anesthetic solution. Significant relief during the immediate numbing period confirms the diagnosis.

    Treatment for SI dysfunction is dependent on the stage of injury (acute or chronic) and on whether the joint is tight or unstable. If the joint is tight and restricted mobilization and stretching is helpful. Hypermobile joints with lax ligaments associated with acute sprains may require strapping braces for support as well as modalites (ice, electrical stimulation) and medication to help alleviate pain. For chronic conditions, a prolonged approach entailing core stabilization exercises and postural education will prove helpful. In the more severe cases steroid injection may provide a temporary solution to control pain while continuing to work on an exercise program to develop strength that will further support the joint. Rarely is surgery necessary but is the last resort to stabilize the joint.

Bill Fabrocini, PT, CSCS

Bill Fabrocini, PT, CSC is a clinical specialist in orthopedic physical therapy and a sports performance training coach. Mr. Fabrocini has also written numerous articles that have been published in prominent journals including the National Strength and Conditioning Journal and the American Council on Exercise Certified News. Learn more about Mr. Fabrocini here.

When I found Jeremy, I was recovering from a herniated disc in my lower back and in quite a bit of pain. Through our work together and the expertise and exercises he has provided, I now have a daily maintenance program for my lower back that has kept me pain free and has me keeping an active lifestyle. I couldn’t recommend Jeremy any higher for anyone who is dealing with low back issues. Complete, comprehensive care second to none.

-Frank Newman, Kansas City, MO

I started working with Jeremy in March of 2015 after struggling with often debilitating back and neck pain due to disc problems, stenosis, and multiple surgeries with varying degrees of success. The chronic pain had really started to erode my quality of life, interfere with sleeping and my enjoyment of my usual sports and other activities. Not knowing how severe my pain would be on any given day started to take an emotional toll as well, as I felt that my activities were limited by my pain level and I was fearful of doing things. Jeremy was excellent at addressing the various joint and muscular problems that were preventing me from fully healing; however, it was truly his attention to ALL the contributing factors related to my pain that was unusual and extraordinary. Jeremy was the first person to address my spine problems holistically, taking into account emotional, nutritional and postural factors. I came to realize that my unconscious reaction to stress would cause increased muscular tension that would really flare up my back and neck pain. As I became aware of this cycle, Jeremy helped me to break this stress response through breathing exercises and increased body awareness. Coupled with an easy-to-follow program of daily maintenance exercises, the results have been remarkable. After working with Jeremy for months, first to assess my musculoskeletal issues taking all factors into account, then working to gradually strengthen core muscles and other vital supportive muscles, I finally reached a place of stability and control. Jeremy taught me a fairly simple routine to maintain the progress I had made. Despite the significant anatomic problems in my spine, as long as I am disciplined and do my exercises faithfully 5-6 days a week, I am able to live my life to the fullest. I now feel like I have the tools and the confidence to understand what is happening if I begin to have a flare up and what I need to do to quickly reduce or eliminate the pain. The best part is that I can now sleep pain-free and getting enough rest is a huge factor in my well-being.

Thank you, Jeremy James!

-Anne Hall, Aspen, CO

I have had neck and back issues for years that have prevented me from doing simple movements such as lifting anything overhead. Certain movements would cause excruciating neck pain that would last for days. I dreaded these episodes so much I avoided these movements at all costs. Chiropractors and physical therapists would always provide me with short-term relief once I was in pain, but they never showed me how to stop these things on my own. Within days on Dr. James’s BACKFOREVER program, it helped me regain enough strength in my back and upper body to allow me to lift overhead without these episodes. In addition, my low back feels better than it has in many years. If I follow the program, I feel great.

-Richard Jelinek*, Co-Founder and CEO of Medicus Systems Corporation Mediflex Systems Corporation, Former Chairman of the Board of Knowledge Data Systems and Lifemark Corporation