Lower back pain is a common complaint in all modern societies and one which exacts a large physical, emotional and financial cost on the individual, be that through lost productive days of work or expenditure on treatment. Financially the impact is significant on society as a whole too, costing vast sums of money to the UK economy. Having an appreciation for the fundamentals of the lumbar spine therefore, is of particular import. After all, how can we possibly seek to remedy something which we have no understanding of. It is this poor understanding of the role of a neutral spine, in conjunction with a poor ability to control and maintain this, that leads so many into practices and treatments for back pain that do not work.
A basic understanding of the neutral spine and its stabilisation would therefore be a helpful topic for us to discuss. Naturally this will lead us to exploring the merits of what might be a good and bad approach to the remedy of back pain.
What is the best position for your spine?
This entirely depends on the circumstances, however we can make some assumptions based on the observations that occur when spinal movement takes place in any given direction.
Firstly if we consider the structure of our spine, it is designed to have a smooth curve to it, a slight backward bend. The curve is elliptical in that there is more backward bending at the lower end of the lumbar spine than at the top. This is only natural as the rate of curve in the low back reduces as we ascend the spine and the curve reverses in the thoracic spine to form what is called a kyphosis, a forward bending curve, with the backward bending curve of the lumbar spine being a lordosis.
You see, contrary to what you might think, a spine that is “straight” would have all the vertebra stacked upon one another and would of course be very efficient at load bearing for static loads. We are however, not trees, we need to move, and such a design would render the main supporting strut of the human body without the ability to absorb shock at all. Therefore, our spine has evolved this erect posture with alternating curves, lordosis and kyphosis, to provide a mix of strength and shock absorption.
In the erect posture, the best position is for the spine is to be as designed. Having a lordosis in the lower back, this allows for load to be borne primarily by the discs and intervertebral bodies, and to a lesser degree the facet joints.
When we think of moving from this optimal position, certain actions take place, for example, as we lean forward, rounding our lower back and eliminating the lordosis, you’ll find the load shifting significantly onto the discs and vertebral bodies, with forces being magnified significantly, the sacroiliac joints flare at the same time allowing a greater degree of mobility to translated into the hip region. Wherever we have an elevation in motion, we must, by definition, sacrifice stability.
To the contrary, when we arch the back, increasing the lordosis, we load and lock up the sacroiliac joints as well as locking in place the facet joints at the extreme. It is however less common on a daily basis that the extremes here are to be reached.
The spine has the right balance of mobility and stability when in its most neutral position and this is the most efficient manner for us to maintain posture.
The secret role of ligaments in the lower back & spine
Before we go further it is worthwhile covering the role of ligaments in this lower back. People all too often focus on the muscles and the discs but we forget that the ligaments provide a degree of rigidity to the whole complex. The balance of ligamentous tension throughout the spine provides a form of pliable tension so that the muscles can act more effectively on the spine. If it were not for the tension of the ligaments we would find that the spine would have little stability to it. It is the balance of tensions between specific ligaments that maintain these optimal curves in our resting and upright posture.
Unlike tendons, ligaments do have a little give, you’ll notice that with a gentle force, you can bend your knee or finger to the side, a movement it does not particularly like. One which you cannot consciously do without external help from the other hand, for example. Without this natural tension your fingers would be wobbly with the wind and prove difficult for the muscles to effectively act on these joints.
The spine is no different. When all these ligaments are healthy and “tense” throughout your spine, when forces transfer through your spine, they do so through one structure, the way it was designed to do so. All the ligaments give to the same degree and no one area, apart from in the extreme degree, will bear more load than any others. This allows our muscles to work with tremendous efficiency, and thus you see the array of feats of physical excellence that we see in all athletic endeavours.
Hopefully you can see how important this balance is, particularly when we think of the lumbar spine and it’s unique “neutral position”. A neutral not with the joints stacked one on top of the other, but the constitution of a curve, with differing angles between the vertebral blocks, with ligamentous support and muscular support. All reliant on these good and ordered balances between the ligaments for optimal functioning in the world.
How your spine position is disrupted
The way we use and abuse our body with actions that replicate our time in the uterus as a fetus more than they do our participation in the wider world. The newborn child is born with one complete curve, from 9 months of development in the womb. Over the coming years of development the balance set within the baby’s ligaments starts to evolve with the strains it exposes it’s spine to as it grows, learns to lift its head, crawl and walk.
The strains of daily activity shape us all as we go through normal development as a human being. This miraculous transformation takes our entire life to the point we become a young child. We then spend several lifetimes in more recent generations working to re-introduce that fetal position, or part of, by way of the endless hours sitting down.
There is one thing that ligaments do not like, that is sustained loading.
Our bodies are built to move, fidget change position, the muscles love this, our cardiovascular system demands this by the very presence of the calf pump mechanism for venous return from the legs, our ligaments need it too! You see, we can round our body completely over one way or the other, the spine is mobile when it is working fully. Naturally some of us may struggle with this more than others, due to the level of flexibility we have developed, often as children.
What the ligaments hate however, is static loading for extended periods of time. Sustained pulling focussed over 10, 20 minutes or longer starts to elicit changes in the ligaments, and changes that do not simply spring back like a muscle that’s been elongated. This sustained stretch leads to deformation of the ligament balance, it lengthens the ligaments. Now think back to that finger example earlier and suppose the ligament on the one side of your finger was stretched more than the other, this would lead to a deviation of the finger, perhaps the muscles would now work improperly, perhaps the joint itself would now become asymmetrically loaded, this could well lead to wear or damage over time.
In a long chain of let’s say, 5 lumbar vertebra, with a thoracic vertebra and sacrum at either end, if one of those ligaments running between two vertebrae were to become stretched more than the rest…
What might that do to the stability of that column?
What might that do to the functioning of that column which should act as one unit, one spine?
It would now focus stress, movement and forces at the weakest point, the phrase springs to mind.
“The weakest link breaks the chain”
Too many of us back injuries aside, spend many years working hard to develop this focus of rounding at the lower level of the lumbar spine in such a one sided way that the weakness develops insidiously. We just do not see it coming until it is too late.
When your back is injured, what then?
It’s commonly this lower lumbar spine that becomes injured, and although writing this Sunday publication I do not have research to hand to quote, I do suspect that this phenomenon may well have some role to play in the sheer frequency with which the L4,L5 and S1 segments are the sight of lumbar injury. You see, having worked on tens of thousands of spinal images over the years, it is clear that degenerative change and damage is not uniform through the spine across individuals. It is focussed in pockets. To the lower lumbar spine most frequently.
It is therefore problematic that there is such a focus on forward bending of the lumbar spine in the early days of lower back injuries. In fact, child’s pose and knee hugs are almost universally recommended as the “standard” early exercises for those with lumbar spine issues. This will often only serve to perpetuate the problem further.
When you’re injured, focusing on restoring your ability to maintain the neutrality of your spine is the focus. Re-learning skills such as to engage the core without tucking the bum under – a pelvic tuck. Restoring your core’s ability to provide stability to the neutral spine and when it is pulled off balance, maintaining the neutral spine in the face of this challenge.
Of course your spine will always move to a small degree. This sometimes leads people to utter words such as “the spine should move”, which it should. But when an area has been assaulted for so long, we have often lost the coordination that we should have to hold that section of the body safe and secure in position. Working to engage your core and covet the neutral spine position will help make you more aware of how your body is being moved.
Frequent aggravations from silly daily tasks is a feature of back pain that is most challenging. This comes from the inherent instability that has been mentioned in this article. We’ve covered the passive stretching and strains on the body causing these changes in detail earlier, injuries of course do the same. As you learn to maintain stability and are more acutely aware of this, you’ll find yourself able to reduce the frequency of these erroneous spinal movements that spark fear and pain.
A strong and neutral spine is the foundation for a flexible and powerful spine and body. Stability, not rigidity should come first for the adult. As children we are born with mobility and are taught to develop stability. As adults the reverse must be observed. In doing so you will have success in keeping your back and body healthy for the long term.
Comment of the week – Keith
“I managed the 14 hour 3 train and a metro journey to south west of France with no problems at all. Thanks for all your advice and support”