OUR MAIN SUPPORT, THE LUMBAR SPINE

Do you get repeated acute episodes of lumbar spine pain, on one or the other side of your back, without doing anything particularly heavy to cause them?

This story is typical of lumbar spinal instability, often due to an early stage of disc degeneration, when discs lose turgor and become a bit sloppy. See further below.

As well as healthy discs, our lumbar spine needs good backup from strong muscles, support being its major function.

Lumbar spine Core stability

Think of your back as like the mast on a small yacht. They both are remarkably delicate structures to withstand very large bending forces as they support a lot of superstructure

A lot of the muscles of our lumbar spine are set at an angle, like the guy wires of a yacht's mast. They protect the back (or mast) from buckling under the load.

The arrows show the position and direction of some of the muscles.

core stability muscles, exercise

You can feel these muscles working if you stand as shown, and keeping your bottom, shoulders and head touching a wall, attempt to hold your body still when you attempt to lift one foot slightly.

Provided you don't help too much by holding something with your hands, this can be used as one “core stabilizing exercise.”

Start with heels about a foot from the wall, and as you get stronger, move them closer. Alternate your right and left feet, as though trying to march with your feet glued to the floor .

Another such exercise is to lay face down on the floor and raise yourself on your forearms and toes, with hands clasped together in front of your face. Hold your chest and tummy off the floor.
I find people can often hold this position for only 10 seconds or so. Practice this until you can hold it for a minute, and don't stop then. This is a long term strategy.

core stabilizing exercise

The more often you exercise your muscles, the quicker they will build up strength. If you work too much too often, the muscles will get sore. Walk the fine line between these outcomes.
This should not increase your pain generally, provided that you don't push yourself to the point when you suddenly collapse on the floor.


Improving core stability can help to prevent putting your back out and so prevent low back pain.

There are lots of such lumbar spine exercises, and so look for some you will enjoy, at "All about abs." Strong supporting muscles go a long way towards protecting us from back ache and sciatic pain.



Stretching and mobilizing your lumbar spine

Recent onset lower back pain will most likely be due to a “mechanical“ fault – a joint in your lumbar spine where it has buckled and become stiff and sore.

The vast majority of people who come complaining of recent low back pain, are improved by mobilizing such stiff lumbar spine joints.

I use this position for examining and treating peoples' lumbar (and thoracic) spines. You can try it for stretching your lower back muscles and mobilizing your lumbar spine joints.

lumbar examination, treatment position

Put a blanket on a table and lay your chest and tummy on it, face down. Your feet are on the floor still, taking the weight of your legs.

Use a pillow if you cannot reach the table with your face. Put some extra padding on the table edge if it is uncomfortable there. See cautions below.

This may already be causing low back pain, due to stretching tight sore lower back muscles.

You may have to let yourself down by degrees, starting by resting on your elbows. It may take a couple of minutes for the pain to ease enough for you to be able to lay flat.

When you can lay flat comfortably, it is time to escalate the stretch.

Put a chair just behind you before you start. Now put up one foot at a time, and rest your toes on the front edge of the chair.

Relax your ankles, and let the whole weight of your hips and thighs just hang, so that your bottom is sagging over the edge of the table as much as it can.

This will cause more pain, so you may have to do it by degrees also, lowering your bottom more as the pain eases in each position.

You will only be stretching the tightest muscle first, and may have to stretch a number of muscles sequentially. The pain may shift a little, as you finish stretching one muscle layer and start on another.

During this stretch, pain may be felt further up your spine or into your buttocks an legs.

If leg pain has the characteristics of deep referred pain, it should ease along with the rest.

This pain is difficult to localize exactly , somewhere inside the limb. It generally has a dull aching quality.

Cautions - please be careful of your lumbar spine

If the leg pain does not have these characteristics, it may be true sciatica, from nerve root pressure. This is a very specific leg pain. It is a sharp pain, close to the surface of your limb and it's easy to say precisely where it runs.

If you are subject to sciatica, and the stretch brings this on, it may be too painful to continue.

My experience of people with sciatica stretching, is limited, so I can't give you any advice on the likely value of it.


I have personally broken one chaps' ribs using this position4. To protect your chest wall you need to have all of your body on the bench, down to your groin. It is more risky for your ribs if you are overweight or have osteoporosis.

ASK YOUR DOCTOR FIRST.

After stretching, then mobilizing your lumbar spine

When you have stretched your muscles and are reasonably comfortable in this position, it is easier to correct mechanical faults in your lumbar spine.

I use this when mobilizing hitched lumbar joints (see below under causes.)

People have told me that they have successfully fixed some recent backaches by the following method (in this same position.)

Wag your tail from side to side, without lifting it. Try to do this loosely rather than a stiff movement. It is likely to be a bit hard on your tummy, which may already be complaining about the table edge.



Mechanical faults are still the most likely reason for recent low back pain, even if you have degenerative disc disease, spondylolisthesis, or have had cancer in the past.

However as in other areas of your body, very sudden onset of severe pain will need urgent medical assessment.



If you are interested in a home study course on examination of the spine, please send me your e-mail address by the contact form.

Avoiding lumbar spine mechanical faults in the first place

Keep moving. Something we don't do enough of these days, although the invention of the Wii is changing this for the better.

Don't attempt too heavy lifting jobs and don't twist while carrying heavy weights - unkind to lumbar spine.

A friend of mine was a family doctor in a dairy farming district years ago, when the change over from milk cans to bulk milk handling occurred.

He told me that the frequency of back injuries dropped dramatically then. Milk cans were heavy.

Everyone still teaches lifting with a straight back to protect your lumbar spine. This has been debunked. Our back is designed to be used bent.

The teaching arose because of misinterpretation of observations made years ago using electromyography and intradiscal pressure measurement. These are respectively measuring muscle contractions from their electrical effects with needle electrodes in the muscle or skin over it and disc pressure with a needle tip pressure transducer in the disc.

It was observed that when fully bent over forwards, the back muscles are electrically silent. They are not contracting. We are hanging on our ligaments in this position.

This was assumed to be dangerous. It is not.

The disc pressure measurements were irrelevant because they were necessarily performed with people quite still, not moving during a normal lift.

Ergonomics are important, if only for comfort. John Holland, MD, University of Washington is quoted as saying "Ergonomic interventions may increase productivity, product quality, and work comfort."

Sounds good to me. I like my kneel chair and sloped desk top. They are very kind to my lumbar spine and upper back/neck/head respectively.

The chair rotates from side to side so that I can be facing the person when we are talking and turn away to concentrate on typing when needed. I don't attempt the impossible (for me) - "multi-tasking."

A dear departed friend, Laurie, once described the oral (viva voce) examination when he obtained his ham radio operator licence. His examiner worked at the railway yards and conducted the examination as he worked, sending Morse code with a hand key for the entire time.

I imagine the sending of Morse code was handled by a different part of the chap's brain to that which quizzed Laurie.

balans kneel chair

Some of the many causes of low back pain, as well as mechanical

Cancer pain is continuous and progressively increasing mostly, rather than intermittent and overall remaining about the same over time.

Lumbar spine pain may be the first indication of prostate or breast cancer. There is usually marked rigidity and muscle spasm evident.

Onset in later life is another pointer to this (and to osteoporotic fracture.)

Another clue to these two conditions, is tenderness on percussion over the spinous processes. This is done by placing one' finger on each bone in the midline of the back in turn, and thumping the finger with the heel of one's other hand.

This doesn't cause pain in ordinary mechanical problems.

In the latter case, the tenderness is elicited by placing one finger between each pair of bones, and giving it a sharp downwards push rather than a thump.


There will also usually be individual levels with mechanical movement blocks, seen on sidebending. See upper back page on this.
lumbar sidebending examination



Here there is a block to right sidebending between Lumbar 4 and 5, shown by my finger marks and a black line over the center of each spinous process.

I described it this way, because that is what you see, the appearance of a level where right sidebending is blocked. As in the old song, it "ain't necessarily so." More correctly it just isn't so at all!

The lumbar spine has bent to the right, but the upper bone of this joint has swiveled on the stuck left posterior joint. This has carried its spinous process to the left.

There is a diagram of this on the thoracic spine page, and I've now added pictures at the end of this page as well.


Do you spend a lot of your time indoors? A blood test for vitamin D deficiency is a very good idea, as this can cause low back pain.


Do you drink mainly caffeine containing drinks? Chronic low grade dehydration can also cause low back pain, according to Dr. Batmanghelidj in his book "Water for Health, for Healing, for Life," pp 152-4.


Inflammatory arthritis is likely to involve other joints in the limbs as well. Stiffness in the morning which lasts at least one hour, is a pointer to this.

The lists of other causes of back pain are very long, but a few deserve mention.

Under active thyroid gland is common and easily missed for years.

Medications such as statin drugs (used for cholesterol,) and bisphosphonates (used for osteoporosis,) can cause muscle pain.

Parkinson’s disease comes on very gradually over decades rather than years, and is well worth looking for as early naturopathic treatment can be very useful.

Kidney infection is not uncommon, so be sure to offer your doctor a freshly collected mid stream specimen of urine for testing.

Pregnancy causes lots of backache, with a baby in front of one's center of gravity, a sway back behind and softened ligaments to help your baby out.

I mobilize any stiff joints, but encourage tummy strengthening exercises as well.
Sacro-iliac joint pain may require support with a sacro iliac belt.

Some of the many other ways of handling low back pain

In "Touch for health" I was taught a correction for "reactive muscles." This is where one muscle or set of muscles, inhibits another abnormally or at least to one's detriment.

Our tight lumbar muscles can be inhibiting our abdominal muscles.

The diagnosis of this condition depends on skills in applied kinesiology, which I learned but haven't maintained. I therefore use the technique below, when my gut feeling tells me to, usually when I've mobilized stiff lumbar joints but the person doesn't feel any better in their back.

It is perfectly safe, and if helpful produces immediate relief.

With the person laying face down, three actions are done at easy intervals of some seconds.

1. They briefly lift their head and shoulders using their back muscles.
2. Facing the persons side, I sharply jab into their back muscles in the small of their back on each side separately. My fingers are all straight, inclined down at 45 degrees towards each other.
The person is warned before I do this, as it is important that they don't react in any way, such as by lifting their head.
3. They then pull their stomach muscles in, without lifting their bottom.

The initial tightening of the back muscles is to signal to the brain about them in some way.
The jabbing action is in the direction so as to shorten the muscles, or to tug on their upper and lower attachments.
This inhibits their action.
Tightening the abdominals is to transfer some increase in tone to them from the inhibited back muscles.



Correcting real or apparent leg length difference, either of which tilts the base of our spine down on the side of our shorter leg.

The spine then has to curve back towards our other side, to keep our body upright.
All this leads to major stresses on the spine, with increased risk of joints buckling under the load.

Heel build-up for true short leg and pelvic adjustment for apparent leg length difference, can improve one's lumbar spine biomechanics and reduce backache.



If your backache isn't too bad, standing Low back muscle stretching can be done just bending forwards to try and touch your toes.
If this hurts a bit too much, support some of your weight with your hands on the front of your legs, and let yourself down by degrees as your muscles release and relieve the pain.

Then bend backwards to look at the ceiling (hands on hips, thumbs pressing into your back.)

Stay in each position until ones' fingers get closer to toes and one can see more of the ceiling respectively - and your pain is relieved.


Rotation stretches are done laying down, moving hips and shoulders in opposite direcions. As muscles relax, move your underneath hip and shoulder so a line down the center of your body would remain still.



Sideways stretch can be done laying down flat on your back and adopting a banana shape position, with arm above head and leg crossed over the other one. This is illustrated on the referred knee pain page of this site.

You will be stretching quadratus lumborum and latissimus dorsi muscles first (then hopefully your paraspinal muscles and spinal joints.)
These are respectively, the muscle in the first illustration on this page, furthest from the spine, passing obliquely between the last rib and the hip bone, and the muscle running up the side of our chest, forming the back edge of our armpit

 Spinal cord stimulation via implanted electrodes, is being further refined and more acceptable.

At the American Academy of Pain Medicine March 26, 2011 meeting, a presentation from the Pain Management & Neuromodulation Centre of Guy's and Thomas' Hospital in London, United Kingdom, described a small study on this.

Two patients of the 30 got nerve irritation and 1 reported the development of a haematoma, but pain was substantially relieved without causing unpleasant sensations.

The key difference from usual spinal cord stimulators, was the very high frequency used (up to 10 kHz.)





Characteristics of lumbar spine instability

1. recurrent acute episodes
2. minimal cause for these
3. catching pain on movement
4. looked at from behind, as bend and straighten, the spine deviates to one side at some stage.
5. the last finding can be prevented by holding your tummy muscles tight as you do the bending and straightening.
6. pain changing sides with different episodes
7. feeling worse soon after you are examined if spine is pushed on
8. small traction spurs seen on X-ray of lumbar spine bones
9. or spondylolisthesis slip (seen on X-ray) at the level of your pain



Do you have low backache when you lay down at night?

This exercise is courtesy of Myer Brott.

Laying on your back, pull your buttocks together tightly and then push the small of your back into the bed.

Stay in this position until the pain eases.



Two sets of springs may be a problem - an inner spring mattress on an inner spring base.

If you have this set-up and lumbar spine pain at night, try your mattress directly on the floor one night. You may be surprised (and delighted.)



Wenatex mattresses have different grades of foam where most of our weight presses, at the shoulder and hip - another approach to an adequately firm mattress.

Camping in the snow some years ago, I had to take off my gloves and put one under my hip and one under my shoulder, to shield the cold and get to sleep. It was obvious where the main pressure was, from the cold.



As well as the lumbar spine, your pelvis may contribute to low back pain

Do you have leg and lumbar spine pain? About sciatica.


Is the backache a bit higher, possibly from your kidney?


More on back muscle stretching.





About X-rays and lumbar spine nasties

A suspicious history with relatively recent onset and overall progressively increasing pain, may be indicative of bone cancer.

Pain disturbing sleep at night and recent unintended weight loss, are also red flag warning signals.

Rather than X-ray, this is better checked by having a nuclear medicine bone scan. The one malignancy which will not show on bone scan is the fortunately uncommon multiple myeloma.

A urine test for Bence-Jones protein is used to pick this disease.

Osteoarthritis or bulging disc does not explain back pain. There is some weak to modest correlation between X-ray and symptoms, but one sees bad OA without any symptoms and minimal OA with severe symptoms.

The spinal level at which osteoarthritic changes are seen on X-ray, doesn't match the level of symptoms well.

One situation in which osteoarthritis may be important is in response to manipulation².

Mechanical disorders can be very adequately diagnosed without X-ray.

Fracture details are better shown by CT x-ray scan.


Disc prolapse with sciatica is better investigated with MRI. The problem with magnetic resonance imaging is that nearly everyone with back pain will have abnormalities shown3 and lots of people with no pain ditto5, so one can't use it to replace clinical judgement.


All this doesn't leave much place for the humble plain x-ray.

Ankylosing spondylitis - also shows on nuclear medicine scan

This inflammatory spondyloarthritis often starts in teenage years. Here pain and stiffness is usually worse in the mornings and during the night, and may be improved by a warm shower or light exercise.

There may be mild fever and loss of appetite.

Apart from anti-inflammatory treatment, regular stretching is very useful here.



Spondylolisthesis - shows on a plain (lateral view) X-ray!

This is almost always an incidental finding of no practical significance. It doesn't alter the treatment one iota.

One bone in the lumbar spine, has slipped forwards (or backwards in retrolisthesis) a little, on the bone below. It is usually a forward slip at the bottom joint, because of the tilt of the bones here.

This often happens because of fractures across the middle of the vertebra, in the pars interarticularis between the disc and the little joints at the back. This is called spondylolysis.

Symptoms usually respond to ordinary mechanical treatment (mobilizing stiff joints etc.)

Large slips are a different matter, and can lead to nerve damage.



Lumbar spine disc disease involvement

The cause of lumbar disc disease, I believe is ischaemia.
My reasons for this are as follows...

I see lots of people with stiff individual spinal joints, where the pain has been diminishing over the days since (the story suggests) the joint buckled.

Many times there are stiff joints which appear not to be contributing to pain at all, and there is no recent history of injury.

Immobility of spinal motion segments (two vertebrae and their connections) interferes with the nutrition of the intervertebral disc.
This has been proven in animal experiments where the bones have been screwed together.

We are shorter in height by the end of the day, as fluid has squeezed out of our discs during the day, to return when we lay down to sleep at night.

This fluid shift plus the normal movement between the bones, is essential for exchange of nutrients and wastes, as the disc has no blood vessels.

Without the movement, the chondrocyte cells which maintain the cartilaginous disc, starve and die.

The disc material breaks down and eventually shrinks.

This spinal motion segment now becomes sloppy and unstable, prone to buckling and getting stuck. If someone repeatedly comes in with the same spinal level stuck, it is likely they are at this stage.

Many years later it is likely to stabilize again, when the disc has largely gone and weight bearing is more or less bone on bone.


Research on athletes¹ has supported the concept. A significant association was found between lifetime experience of low back pain, and the presence of degenerative disc disease on MRI scan.

There was a good match between the severity of their worst low back pain experience, and the presence of degenerative disc disease.

I believe it is likely that their episodes of lumbar spine included inadequately treated buckled joints (osteopathic lesions,) where the pain resolved but the joint remained stiff.



In the acute setting, with recent onset of low back pain, one can seldom deduce anything about the state of the intervertebral disc.

Occasionally it is obvious. A lesion at Lumbar 4-5 can cause a dramatic "sciatic" scoliosis.

sciatic scoliosis

The gap between elbow and waist is wider on this woman's left side, because of her tilt to the left at the level of her lumbar spine.

If you want to see this more clearly, make a plumb line with some cotton and a weight, and dangle it against the computer screen midway across her hips.
Her shoulders are over to the left.

When severe pain persisting after mobilizing stuck joints raises suspicion of discogenic pain, I apply vertical traction in the seated position. If this relieves the pain while I am holding them up under their shoulders and pain returns as soon as the weight is again on their back, I take it as probably pain from a disc annulus tear.



Another finding on examination making one suspicious about the discs, is long standing tenderness on springing a spinal joint.
This is in the setting of continued low back pain despite restoration of normal movement.

Sudden pressure is applied to a finger laid over the interspinous ligament between the adjacent spinous processes.

(This is not specific for the disc, also tender with arthritis of the posterior joints. These are pairs of little synovial joints connecting the vertebrae at the back. They get osteoarthritis, inflammatory arthritis and little fractures which are too small to show on an X-ray. They probably get internal derangements like our knee or jaw joints.)


Such a joint with long standing tenderness from disc disease, may be aggravated by a stiff joint or joints at different spinal levels, and may be even hypermobile, even with clicking or crunching on movement. I have only heard this latter situation in the neck, but painful hypermobile joints occur in the lumbar and thoracic spine.


A nuclear medicine bone scan may be useful now, in case there are one or two posterior joints with a lot  more activity, which can then be injected with cortisone or denervated by radiofrequency probe to their nerves.





Scoliosis - twisted spine, ideally found in childhood

When someone bends right over forwards, the ribs on each side should be on the same horizontal level.

This is a very quick and simple test for scoliosis, when the ribs will be higher on one side.

This is treated exactly the same as any other mechanical back complaint.
Finding which posterior joints are stiff is a bit tricky now, because of the extra curve.
Muscle stretching is a very large part of the home treatment, to gradually get the muscles the same on the two sides.
Breathing exercises to expand the smaller lung, are included.

One also has to wait for growth to correct the inequality of the two sides of the body.



Diagrams of lumbar spine posterior joint examination

The black lines are parts of the lower margin of the lumbar spine vertebra above that pictured, the black shaded areas the parts of the two bones you can feel at the back.

The edge of the upper vertebral body (the front of the bone) is the kidney shaped black ring. The intervertebral disc is the space between this black ring and the upper surface of the pictured bone. The disc is between the two bodies.
The inferior articular processes are the U shaped lines, and the spinous process is the bit you feel, sticking out the back.

Lumbar vertebrae normal lordois

The second picture is when bending forward.
Carefully compare this next picture with the first.

The front and back heights of the intervertebral disc, are now equal, as the normal backward tilt (the lumbar lordosis) has straightened out.

The articular processes and the spinous processes of the two bones, have moved apart, equally on the two sides.

Lumbar vertebrae no lordosis - flexed

Now the person has bent to their left, from the last position.

The upper bone has tilted to the left, as seen by the tilt of the body and spinous process of the upper bone.

The articular processes on the right side have separated further, while those on the left have closed up.

Lumbar vertebrae normal sidebending from flexed position

This last picture is what I believe happens when a (right posterior) joint is hitched. It explains the findings on examination, but is an unproven hypothesis.

The person has bent to their left, and the upper vertebral body has been pulled to the left.

The right sided posterior joint is stuck somehow, and I have shown it in the same position as in the second picture.

The upper vertebral body has swiveled around as it was pulled to the left, with this stuck joint acting as the fulcrum or axis of the rotation.

The upper spinous process has been carried to the right by this rotation, producing the step you see in the curve of the bones.

Lumbar vertebrae abnormal sidebending

It would be quite easy to prove in an institution with appropriate 3D X-ray equipment.



KIDNEY PAIN PAGE

SCIATICA PAGE





Professor Nikolai Bogduk of the Bone and Joint Institute of the University of Newcastle, has written a very well researched summary of the literature on chronic low back pain management.

This Medical Journal of Australia article can be found at...


www.mja.com.au

Neuropathic or mixed low back pain

By the time low back pain has become chronic (long standing,) perhaps a third of people have some of their pain from damaged nerves as opposed to normal nerves and damaged muscles, joints, discs and ligaments.

You can get a cue about this by your symptoms, using questionnaires such as the DN4. "Hypoesthesia" means less feeling. "Brushing" is just light brushing across the area with your fingers.




Notes and references for lumbar Spine page

1. Mika Hangai et al lumbar intervertebral disc degeneration in athletes. Am J Sports Med January 2009 vol. 37 no. 1 149-155

2. Mr. B, aged 50, was stiff and sore if he sat too long, for three months, after had suddenly hurt his back gardening.

On examination his lumbo-sacral joint was hitched on the right side. I manipulated it free. He had 3 upper lumbar joints stiff and sore in keeping with osteoarthritis.

The result of this treatment was one week of aggravation then back to the same as before the visit. This is fortunately an unusual response to manipulation, but more common when a person has underlying osteoarthritis. Osteoarthritic joints don't take kindly to injury.

3. oxfordjournals.org.abstract

4. R.I.P. Bill, 2017 - many years after the broken ribs.

5. Magnetic Resonance Imaging of the Lumbar Spine in People without Back Pain



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If you are interested in a home study course on examination of the spine, please send me your e-mail address by the contact form.