Life is a gift bestowed upon us by Nature and God. To savor this gift to the full, one needs a healthy life. Diseases tend to upset the rhythm of our life and may spell doom to this joyous gift of God. Diseases are the darker faces of life-threatening our very existence. Some of the diseases are not our making and hence not in our control while a majority of them are man-made and is due to the abuse and insults we hurl upon our bodies knowingly or unknowingly. Backache is one such disease created and nurtured unwittingly by us.
Among all the maladies afflicting the human race backache ranks second, next only to headache and common cold. It is ubiquitous in distribution, cuts across all races, culture and geographical barriers. It is infamously known as the modern international epidemic. However, its existence is not new having been known from the beginning of the history of mankind.
HOW IS BACKACHE DIFFERENT FROM OTHER DISEASES?
As already mentioned, it affects people all around the globe rich or poor alike! Every human being suffers from this problem at some stage of life.
It is known to affect 8 out of 10 people. It goes away easily with simple treatment only to return back with a vengeance in 7 out of 10 cases. In about 7 to 10% of the population it stays forever. What is more intriguing is that in 7 out of 10 cases it resolves on its own without much treatment. These features of this disease give rise to the optimism that it can be collared and conquered (Fig. 1.1).
Since it affects a large population it leads to decrease workplace productivity and is a leading cause of sickness absenteeism. Add to this the enormous cost of treatment and economic imbalance of the individual and the country and the misery is complete.
WHAT IS THE BEST WAY TO DEAL WITH BACK PAIN (FIG. 1.2)
Backache is a growing menace, and it can be best tackled by acquiring sound knowledge about the various aspects of your back. An effective strategy should follow the protocol as mentioned below:
- Try too understanding everything about your back.
- Know the structure of your back and how it works.
- Try to know what causes your back to ache.
- Know about posture and the value of acquiring good postural habits.
- Know the importance of exercise in keeping your back fit.
- Acquaint yourself with information about the various investigations your doctor advises you for backaches.
- Try to know various treatment methods of backache.
- You should know when to see a doctor because all backaches do not require the services of a doctor.
- Try to know the ways and means to prevent recurrence of your backache.
Let us begin with first thing, first by trying too know how our back is designed?
DESIGN OF YOUR BACK
It definitely makes lot of sense to know how your back is designed before knowing all about the backache.
What is Back?
It is the rear portion of our neck, shoulder, chest, abdomen and pelvis. Accordingly it is divided into neck, upper back, midback, lower back, seat bones and tailbones (Figs 1.3A and B). Backache may strike any of the above address but it has a greater affinity for the lower back and the neck.
Structure of Your Back
Your back is a specialized stretched designed with great precision and accuracy by God. It is a family of bones, muscles, joints, ligaments, and nerves. They all join hands together to form a good flexible back. Bones form the frame of our back, and this in turn seeks the help of muscles and ligaments for support, stability and movements.
Figs 1.3A and B: Your back extends from neck above to the tailbone below.
A: Spinal curve appears straight from the back.
B: Spinal curve appears S-shaped from sides.
A bony column called the spine forms the center of our back. It is not a single but a vertical complex of 33 small irregular bones called the vertebrae. These bones are stacked one over the other in an excellent demonstration of layered engineering. These vertebrae are connected with each other through the facet joints. Interspersing between the vertebrae are elastic structures called the disks. These give your spine its mobility apart from functioning as shock absorbs.
The spine is divided into five areas (Fig. 1.3):
- Cervical area (Neck): This is made up of seven bones. The movements of the neck are flexion (forward bending), extension (backward bending). Sidewards bending and rotations. It allows the head to move freely. It also bears the weight of your head.
- Thoracic area: This is made up of 12 vertebrae and there is very less movement and rotation in this area. Spinal cord injury is very common here. The ribs in the thoracic area provide stability to the sternum (called the breastbone).
- Lumbar area (Lower back): This is formed by five thick vertebrae. Here forward, backward and side bending and rotation takes place. This area receives the most stress and strain.
- Sacrum: Five vertebral bones fuse to form the Sacrum. It forms the back portion of the pelvis.
- Coccyx: This is made up of fused bones, which represent our extinct tail.
Figs 1.4A and B: The appearance of your low backbone (lumbar vertebrae) from above (A) and from sides (B)
After having known how the thirty-three vertebral bones are arranged in five different regions, let us now try to know how an individual vertebra looks like:
- Body: The front section of the vertebra is drum-shaped and it bears some of the burden of body weight transmission.
- The rear section: This is an arch formed by the bony projections (transverse process, lamina, pedicles and spinout process) to which the bad muscles and ligaments are attached.
- The facet joints: The vertebrae join with each other at the facet joints, which are hinge shaped. These joints are responsible for the movements in between the vertebrae.
- The arch: At the back forms the spinal canal in which the all-important spinal canal lies.
Disks
Your disks are remarkable structures, which unfortunately are much maligned as people keep referring to it as a culprit for much of their back problems.9
Fig. 1.5: Note how your disks are placed in between the vertebrae bones. Figure above shows various ligaments of the back
Nothing is farther from truth when you consider the role it plays in smooth functioning of your back. Some of its salient features are:
- It is situated between two vertebrae (Fig. 1.5)
- It has a tough exterior (due to elastic fibers) and a soft gelatin like substance in the interior (mostly has water inside). The former is called the annulus fibrosus and the latter, the nucleus pulposus (Fig. 1.6)
- It serves as a cushion between the bones and hence functions as a shock absorber.
- Due to aging the disks dry out and the flexibility is reduced.
- The outer fibers tear; heal with scar tissue, thereby reducing the flexibility as age advances.
- It absorbs water during the night and loses water during the day.
Role of Your Back Muscles and Ligaments
Providing support and stability to your backbones are various back muscles (log, medium and short) and ligaments (Fig. 1.7).10
If your bones from the skeletal framework, holdings this frame erect and supporting them are your back muscles are instrumental in providing the all-important mobility to your spine. Some of these muscles are short and are attached to the individual bones, some are medium sized which11 are attached to groups of vertebrae and some are large as they run along entire length of your spine. Acting together they bring about the various movements of your spine. Various back ligaments provide stability and support to the bones and joints of the back (Fig. 1.5).
Nerves
Functions of your lower limbs enable you to walk, sit, climb, run, squat etc. You decide to do certain activity and your brain commands your legs to do it. Thirty-one pairs of spinal nerves convey this message from the brain to your legs and vice versa (Fig. 1.8). They emerge out of your spinal cord, which is nothing but an extension of your brain. The vertebrae apart from carrying your body weight protect the all-important spinal cord, which is positioned within the bony spinal canal. The spinal nerves emerge through holes in between the bones called the intervertebral foramen (Fig. 1.9) to reach different parts of your trunk, abdomen and lower limbs. Now you realize why if there is pressure on these nerves at the back, the pain is left in the legs.
Arrangement of Your Spine into a S-shaped Structure
So you know that your back is not made up of a single long bone but multiple small irregular bones. These thirty-three bones are not arranged in a straight line but are arranged in the form of an S-shape curve. You will be surprised to know that in animals this configuration is C-shaped. Since animals walk on all the four limbs, the spine takes the form of a C-curve but only in you and me it is shaped S! In the early part of our childhood when we crawled on all four limbs our spine also had a C-curve. As the child gradually learns to stand and walk on two limbs, the C-curve gives way to the S-curve (Fig. 1.10).
This S-curve, Nature's Plan for us Human Beings
I am sure you will be inquisitive to know why you have an S-curve and how is it beneficial to you! I will explain to you. I am sure you have learnt at school that you, as a human being is an end product of thousands of years of evolutionary changes. Earlier we were animals and our ancestors were monkeys. Then we were walking on all the four limbs and we had a C-curve in our spine.
The Bible says we, as human beings are replica and exert our supremacy over the animal kingdom, may be our ancestors might have felt, one way to stamp our superiority over them was to stand tall on two legs instead of walking low on all the four limbs. So during the evolution, when we stood on two limbs instead of four, little did we realize that our spine would be at the receiving end.
How has this S-curve Evolved in We Humans?
You are well aware any object that is thrown up does not continue to go up but come down! You are also aware that Newton, the famous scientist, while resting under a tree was surprised when as apple fell on his head. He wondered why the apple came down instead of going up? It is Mother Nature, which attracts the objects towards it through its forces called the gravitational forces. Nothing, practically anything on this earth can escape the effects of these natural forces (Fig. 1.10).
Now in this backdrop, imagine what happens to your spine when you stand up erect on your two legs, the earth's forces pull down your whole spine. So whenever you stand up, you should be hurting towards the ground! But in reality that does not happen and you continue to stand erect in spite of these forces. That means there is some force behind your back, which is helping you to resist these gravitational forces. These forces are definitely more powerful than the antigravitational forces generated by the action of your back, buttocks, and thigh and leg muscles. Sandwiched between these two opposing forces, your spine is forced to develop an S-curve to balance your body when you are on your two legs. Your head is pulled down by the gravity and the back neck muscles resist it, resulting in a forward curve of the spine in the neck (lordosis). Immediately beneath the neck is the chest portion, which develops a backward curve (called the Kyphosis) to oppose the forward curve14 in the neck. Beneath the chest is the lower back, which now develops a compensatory forward curve as in the neck (called the lumbar lordosis)! These results again in a backward curve in the region of your pelvis (called sacral kyphosis). Thus, there are two backward and two forward curves in your spine resulting in the S-curve. In a way it can be said that this S-curve is a compromise struck by your spine while appearing these two powerful forces.
In other words, it can be said that this S-curve in the spine is an inevitability due to our two-legged stance. By now, I hope, it might have become very clear to you that is the muscles which I mentioned previously that are instrumental in developing and maintaining this S-curve. So now it is obvious that nature is clearly justified in providing us an S-curve instead of a C-curve. Since S-curve is designed and accepted by nature it is imperative that you do not violate this design by your ignorance and carelessness. So while your spine assumes this S-curve, you continue to stand erect and appear straight to the discerning eye while actually you are not straight (Figs 1.11A and B).
Advantages of Your S-curve
C-curve is ruled out for us since it is a design for the four legged. Since we possess the S-curve there has to be some beneficial effects accruing out of it namely:
- It makes your neck look taller. It gives a beautiful shape to your neck. That is why the jewelery around a female's neck and the tie around a male's neck look impressive.
- When you bend forwards and get up to lift a weight, this S-curve provides an incredible lifting force for your spine.
- The mobility your spine enjoys is because of these small bones and their S-curve.
- A perfectly balanced S-curve gives you a good shape. You look gawky, when say, you develop a potbelly, which pulls your spine forwards and thus distorts your S-curve.
After knowing all about the structure of your back, now let us turn our attention towards various functions the spine performs in your body.
FUNCTIONS OF YOUR SPINE
Though there may be plenty of instances of individuals wasting their precious lives doing nothing there is not a single structure in your body, which remains idle doing nothing. So is the case with your spine. It is not a defunct structure but a very useful one, performing not one but multiple roles in your body. You will start admiring and respecting your spine once you come to know how much it works for you to make your existence in this world a pleasant and useful one!
Weight Transmission
Do you know that your 50-60 or say 70 kg weight of your body has to be transmitted to the ground the moment you stand erect? And do you know who does that for you? Yes you guessed it right, it is your spine. Not only that, apart from your weight, whatever additional16 loads you carry on your shoulder, arms or any part of your body, it is your spine which takes up the responsibility of transmitting it! Carrying and transmitted weights is no joke considering that just your head weighs around 11-13 lbs!
Process of Weight Transmission
Weight transmission takes place in an organized manner. Starting from the head, neck, shoulders and arm, the weight reaches your spine through the hydraulic function of your chest and abdomen. From the spine it reaches your pelvis through the sacrum and then to the hip joints, your lower limbs, heel, feet and then to the ground! In transmitting the weights your spine seeks the support of your back muscles, ligaments, facet joints, body of the vertebrae and the disks (Fig. 1.12). Each contribute in their own way towards weight transmission and reduce the burden on the spine. Now in case if you lift a weight suddenly, your muscles are caught napping or off guard as they are not ready for the extra effort. These put a sudden stress on your bones and disks and overload it abruptly resulting in disk slip or rupture, muscle or ligament injuries causing agonizing pain. Similar results happen if you do an unaccustomed activity.
So now you realize that weight transmission in your body is an active and continuous process which causes enormous pressure on the spine in any posture except lying down! Hence, lying down is least stressful to the spine as it takes away the cumbersome weight transmission process of your spine (Fig. 1.13).
Movements
Every body you bend forward, backward, sidewards and even rotate your back to carry out your various day-to-day activities (Fig. 1.14). Likewise your neck also does these activities for you. Is it not surprising that your spine does so many movements for you unlike other joints in your body, which only do one or two movements?
Imagine yourself with a spine doing only one or two movements! All this is possible because of the unique vertebral configuration designed for you by God.
Protection
The spinal cord is the continuation of your brain. Just as the skull protects your brain, the spinal canal formed by the back elements of the vertebrae, protect the delicate and all-important spinal cord. The intervertebral foramen protects the spinal nerves emerging out of the cord. Whenever there is a fracture of the vertebral bodies or a slip, this spinal cord or nerves are damaged to neurological deficits.
Know the Pressures Your Spine is subjected to, Day in and Day out
Hope by now it might have dawned on you that it is an established entity that we are destined to assume a two-legged stance. Whenever we assume an erect position be it standing or sitting, remember our body weight needs to be transmitted through our spines. This apart, we need to carry, put various activities like bending, twisting, lifting weights, etc. in these positions. More importantly your spine is thrust with the onerous task of defying the gravitational forces. Do not you think that your spine is subjected to enormous pressure due to gravitational forces, weight transmission and varied movements one needs to perform on assuming the upright stance! Now imagine the magnitude of pressure on your spine when you perform activities like running, climbing, walking, jumping etc. Barring those few months in your early childhood when you spine needs to withstand the above pressures for the rest of your life.
Assuming you sleep for 6 to 8 hours every day, the remaining part of 16 to 18 hours is spent sitting, standing, walking, climbing, etc. This is not for one day but for the rest of our life span. So you can well imagine the brunt of the load your spine when assuming the demanding erect positions? I am excited to tell you that it is possible indeed. And the way to do it is by adopting postures which maintain your S-curve.
EVERYTHING YOU NEED TO KNOW ABOUT HUMAN POSTURE
When you are on your feet, assume a posture, which is correct and optimally load your spine. Posture is nothing but the relationship between various parts of your body with respect to each other.19
The ideal posture is one, which helps you to maintain the normal S-curve of your spine in all positions of standing, sitting, walking, sleeping, etc. As long as you maintain this S-curve, your spine will be better equipped to do the demanding functions during the erect postures (Fig. 1.15).
So the posture which the nature has recommended for you and me is an S-curve! In this position, few muscles are required to function to maintain it that way and the vertebrae, joints, disks, ligaments and muscles uniformly share the weight transmission process. For this to happen your posture should be protected! Do you know what happens when your posture is not correct? In an effort to maintain the improper postures adopted by you, numbers of back muscles are brought into action. This leads to early fatigue of these muscles. With the support, provided by these muscles during the weight transmission no longer there, more stress and strain is shifted to the bones, disks, joints, and ligaments during the weight transmission. This imbalance wears down these structures and sows the seeds for future backache.
YOUR LIFE DAY IN AND DAY OUT
You are guilty of humiliating your spine everyday due to the faulty postural habits you inadvertently follow. Consider this, You stand awkwardly, you hunch over the tables, walk gawky, while driving you slump in your car seats, sit awkwardly on your two wheelers. It is20 tragic that with every passing minute you are unwittingly spelling doom to your back. (Discussed in greater details in the next sections)
ALSO CONSIDER OTHER FACTORS BURDENING YOUR SPINE
There are some factors that are not in your control like the roads ridden with pot holes, humps, bumps, poor working conditions, poorly designed chairs, overcrowded buses, trains, etc. make matters worse for your backs. As if this is not enough you seldom exercise and keep yourself fit. You have no time to do this as you are stuck in the drudgery routine of your life. So your muscles are understoned and unable to offer support and stability to your crumbling spine. If you are obese and pot bellied this puts additional burden on your already beleaguered spine by distorting the S-curve and pulling it forwards (refer to Fig. 13.7)
Now imagine the facts the fate of your spine when the inevitable effects of aging are clubbed with the factors I have already mentioned. As your back ages, the bones become soft and brittle, the disk loses water and dries up and breaks, the ligaments loose their elasticity, the muscles are less flexible and the joints are worn out. So the combined effects of aging, poor posture, lack of exercises, obesity, poor environmental and working condition, bad roads, etc. are catastrophic to the well being of your spine. It retaliates unable to tolerate the insults heaped on it by you. So this is how one now realized that the backaches you experience are not a single day's affair but it is the end result of the sins of the bad postures, aging, etc. over years.
WELCOME TO THE WORLD OF BACKACHES
Before dwelling into the details of pain in your back, let us begin with the basics, as to what is this backache all about?
It has already been mentioned that your back is made up of the rear portions of the neck, shoulder, chest, abdomen and pelvis. And hence accordingly it is divided into neck, upper back, mid-back, lower back, seat bones and tailbones. Backache may strike any of the21 above but it has a greater affinity for the lower back and the neck in that order of frequency (See box below).
LOW BACKACHE
Now having known that low backache is the most common variety of the back pain one encounters, let us focus our attention on this and try to acquire suitable information about this ubiquitous problem (Fig. 1.16). The purpose of this book is to equip you with knowledge so essential to tackle this growing menance worldwide and it may be in your own backyard too!
Causes of Low Backache (LBA)
I am sure you will be curious to know what causes your lower back to ache. There are a plethora of causative factors, some common and some uncommon, some related and some unrelated to your spine.22
Do not be surprised if I tell you that you are responsible for creating a monster in your back by contributing generously for its genesis. The uncommon contributing generously for its genesis. The uncommon reasons are far fewer in number (20%) and you cannot be blamed for it, for you have no role either in its causations or its23 cure but you are largely responsible for the common low backache which accounts for nearly 80% of the cases. I felt a necessity to write this book since you are the originator of this malady of common low backache and logically you should be its terminator too! But ironically you look towards us doctors for exercising the ghost created by you. While the answer lies largely with you, it is at your own oriel you overlook this important aspect and invariably, both you and your doctor, come a cropper in cornering this genie. Now let us analyze the reasons for your backache, first the uncommon ones and later, the common ones.