You wake up one morning and try to get out of bed, but a sharp, knifelike pain in your back makes you freeze. The warmth of the shower eases the pain a little, but periodically throughout the day you feel a dull ache. You begin to worry that you are getting old, that you have a serious condition that might need surgery, that this is the beginning of the end. You are not alone.
Spinal discomfort and pain are part of the human experience. We health care professionals, experts in back and neck pain, even experience it, too. Estimates are that 95 percent of the population will have at least one serious episode of spinal pain in their lives, and 84 percent will suffer multiple episodes. Of those, 33 percent will suffer from chronic pain, and 7 percent will be substantially limited in their ability to work.
Spinal pain is the second most common reason for a medical office visit and the most common reason for emergency room consultations in the United States, totaling 6 million visits per year. Spinal pain costs an estimated $110 billion per year, and another $40 billion is accrued in business expenses.
The incidence of spinal pain and location varies by occupation and gender. The low back area constitutes 70 percent of all cases, the neck 22 percent, and the midtorso 8 percent. Men are twice as likely as women to have repeated attacks, and they occur in 50 percent of those who do hard labor. Women in the white-collar workforce (secretaries, lawyers, and teachers, for example) more often have neck and shoulder blade pain. An estimated 50 percent of them have other difficulties as well, such as chronic headaches, carpal tunnel syndrome, and thoracic outlet syndrome. A spine specialist and a neurological assessment are needed in these cases. Otherwise, a non-neck problem may be mistakenly diagnosed. The number of people with spinal pain at any one time is about 60 million. An estimated 40 million suffer from chronic spinal pain.
Table of Contents
- Back and Neck Anatomy
- Movements of the Spine
- Origin of Anatomical Terms
- Why Does it Hurt?
- Evaluating Your Pain
- Spine Pain Test
- Common Causes of Spinal Pain
- What Is a Flexion-Biased Lifestyle?
- Postural Syndrome
- Is It Postural Syndrome?
- Spinal Derangement
- Is It Derangement Syndrome?
- Adaptive Shortening
- Is It Adaptive Shortening Syndrome?
Back and Neck Anatomy
The spine is like a row of houses. Each house is a vertebra. There are 7 cervical (neck), 12 thoracic, 5 lumbar, 5 sacral, and 4 coccyx vertebrae (figure 1.1).
Feel the bones at the back of your neck and lower back. These bones, the spi- nous process, are like the steeples of houses. The spinous process comes off the roof of the spine, the lamina. A laminectomy is an operation in which the lamina is removed. The spine is not solid bone. It is mobile. Ligaments are present between the laminas at each level. The walls of each house are made of pillars, the pedicles.
The foramen is like the window of a house. The nerve exits the spinal cord through the foramen to go to the arms or legs. A foramenotomy is a surgery on the window to relieve nerve pain. The facet joints attach one vertebra to the next. Each vertebra is numbered: C1 to C7 in the neck and L1 to L5 in the lumbar region. Joints, inter- vertebral discs, and ligaments are located between the vertebrae. Each vertebra has some mobility because of the facet joints and ligaments. The pedicles attach to the vertebral bodies, which attach to the intervertebral discs. An intervertebral disc is a multilayered ligament that looks like a woven basket. It is laminated with multiple layers like the belts on a truck tire. The disc attaches to the vertebra above and below and allows motion between the vertebrae. Two facet joints behind the intervertebral disc make up a joint. For example, L4–L5 has a disc, two facet joints, and its own nerves. If it is injured, it hurts. The joint will swell and become inflamed like any other joint. The spinal canal runs through the vertebra. The spinal cord is in the neck, and the cauda equina is in the low back. Ligaments under the roof and floor of the vertebra allow movement and provide structural strength and protection of the spine.
If the intervertebral disc develops a tear between its layers and its dense liquid center, or nucleous pulposa, bulges out, a disc herniation has occurred. A fragment of the disc that extrudes into the spinal canal in the neck can be extremely danger- ous and may cause paralysis. A combination of the disc bulge, ligament buckling, and joint arthritis can seriously narrow the spinal canal, the living space for the spinal cord and cauda equina. The result may be a slow or sudden loss of strength, bladder control, and sensation. This condition is called spinal stenosis, a narrowing of the spinal canal.
The nerves run through the body, starting at the brain and extending all the way down to the bottom of the toes. The nerves help the doctor pinpoint the level of the spine at which the problem occurs, identify the nerve involved, and determine the specific problem, based on patient history and the physical examination.
Movements of the Spine
The spine can flex, extend, bend laterally, and twist. It is a wonderful feat of engineering. These movements change the relations of the spine anatomy. Anyone with back or neck pain knows that certain movements provoke or worsen the pain. These biomechanical functions—flexing, extending, lateral bending, and twisting—are used during the physical examination to diagnose the cause of pain. When you bend forward (flexion), the spinal canal and foramen open. When you arch your neck or back backward (extension), the spinal canal and foramen close. Patients have various symptom complexes, symptoms based on spinal motions that take these biomechanical factors into account.
Origin of Anatomical Terms
Do not be intimidated by the medical anatomical terminology, words such as cauda equina, sciatica, stenosis, cerebrum, cerebellum, and medulla oblongata. These terms were coined by the early fathers of anatomy. What were these great minds thinking when they came up with these tongue-twisting multisyllabic terms?
Consider the brain. The brain consists of three parts: a large part; a small, delicate, and intricate part just under the large part; and a center like a middle stalk going through the brain. The cover of the large part is yellowish, shiny, and gray, much like a candle. Candle in Italian is cere, meaning “wax.” Brum means “big,” so cerebrum means “big wax.” The smaller delicate part, shiny and bright, is the cerebellum, from cere for candle and bellum, which means “beautiful,” so cerebellum means “beautiful wax.” The long middle part is the medulla oblongata from the Latin meaning “the long middle thing.” The terms aren’t so intimidating in this context.
What about the term cauda equina? Cauda means “tail,” equina means “horse,” so cauda equina means a “horse’s tail.” At the end of the spinal cord is the lumbar sacral spine. Because it gives off the nerves that become the sciatic nerve, it looks like a horse’s tail.
The word sciatic or sciatica originates from the Italian word for skiing, sciare, which means “to cascade.” The nerve cascades down from the horse’s tail like a ski slope. Medical terminology is simple if you understand the language, which is Latin in this case. Pain, however, is a universal language (“Ouch!”). Each ana- tomical part has a particular symptom or pain, its language.
Why Does it Hurt?
The transmission of pain involves the exchange of chemicals within three major components of the nervous system: the peripheral nerves, spinal cord, and brain.
At various stages, these three components trigger, transmit, and receive electrical impulses that we perceive as unpleasant. The three types of pain-provoking stimuli are chemical (swelling), temperature (hot or cold), and direct mechanical pressure. Pain-transmitting nerve fibers have an extremely small diameter. They originate from almost every structure in the body, eventually joining with the spinal cord as it travels up to the brain.
The pain impulse instantaneously enters the thalamus, the brain’s switching and sorting center. From here, the information immediately passes to three specialized areas of the brain. From the thalamus, pain impulses move to the somatosensory cortex. This area allows you to interpret physically where the discomfort comes from—your toe, lower back, or deep in your chest. This interpretation of location is important. Generally, we give more significance to symptoms that are perceived to be deeper than to those that seem more superficial. Identifying the area of discomfort is especially important when you describe your pain to your doctor or therapist. As you will learn in chapter 2, each pain-producing structure has a voice. By giving an accurate history and description of your pain, you help your doctor or therapist know which structure is talking to you.
The cerebral cortex, the active thinking part of your brain, helps decipher the urgency or severity of your symptoms and directs you to a course of action. Impulses pass to the frontal cortex as well. This area in your brain allows you to give meaning to the experience, as in “This is no good,” “This really hurts,” “This will go away soon,” or “This needs to be addressed.” This response stimulates the decision-making process so that you can decide whether to seek care. Do you miss work, skip the game, go to the hospital, or simply carry on cautiously? This decision will vary from person to person. You may already have seen your health care provider for a similar discomfort in the past and learned to be patient, confident that it will pass with a little self-help. Or you may be experiencing neck discomfort for the first time and, based on other influences such as your uncle’s bad experience or a neighbor’s well-intentioned advice, decide to make an urgent trip to the emergency room. The significance that we place on the spinal pain that we feel in large part dictates how we respond to it. Throughout the book, we’ll provide some guidelines on what is urgent and what is not.
The pain impulse also travels to the limbic area. Here the brain assigns an emotional significance such as suffering, frustration, anxiety, or fear to the impulse. Because emotional significance is part of the pain-perception process, similar types of stimuli cause different reactions in different people. For example, the anxiety felt by someone who has never been to a dentist when he hears the drill or sees the cleaning probe may accentuate his sensation of discomfort. Or the stress and fear of losing a job or athletic ability may complicate the healing process of an otherwise manageable spine injury. Conversely, some people, such as athletes, use the emotional significance of winning to block out and endure more discomfort.
Within the brain, chemicals moderate the incoming pain signals, either dulling or amplifying the experience. These chemicals are released by the cells in the brain and are influenced by the self-help recommendations provided in later chapters. Following the guidelines that we provide will help you increase the release of pain- dulling chemicals and reduce the presence of pain-amplifying chemicals.
Emotions, fears, anxieties, and apprehensions can either open or close the valve controlling these chemicals, thereby assisting or complicating the perception of pain. Depending on a variety of factors, especially their experiences, some people have a better override mechanism than others do. This trait helps them heal and recover more quickly.
Inflammation also influences your perception of pain. In part, chronic pain arises from inflammatory processes that sensitize the nervous system, causing the nerve fibers that send pain impulses to fire more easily, frequently, or intensely. This pro- cess can occur within all centers of the pain pathway and may explain why small events can have a significant effect on those already experiencing chronic spinal pain. Modulating inflammation through exercise, diet, sleep, and relaxation, as discussed in chapter 5, is key in the overall management of chronic spinal pain.
Evaluating Your Pain
Patient attitudes have changed. In the past, patients simply said, “Fix it, doc.” Now they ask, “What is my problem, and what can I do about it?” This book is about empowering you to understand why you hurt and what you can do. End Back and Neck Pain will be your companion. Let’s begin by identifying what your spine pain is telling you. Take the spine pain test.
Spine Pain Test
- Is your spine pain severe, sharp, and stabbing? Yes or no.
- Is your pain more in your arm or leg than in your spine? Yes or no.
- Does your pain radiate from the spine down your arm or leg? Yes or no.
- Is your pain most often associated with tingling, numbness, or burning? Yes or no.
- Does looking up at the ceiling make your neck or arm pain worse? Yes or no.
- Does bending, lifting, or twisting make your back pain worse? Yes or no.
- Do you notice weakness in the painful extremity? Yes or no.
- Does standing in one spot make the pain worse? Yes or no.
- Do your legs get weak after walking a certain distance, such as one block? Yes or no.
- Does rest make your pain better? Yes or no.
- Does rest make your pain worse? Yes or no.
- Is the pain worse in the morning? Yes or no.
- Is your pain mainly a stiffness that gets better with exercise? Yes or no.
- Has your pain persisted for more than three months without getting better? Yes or no.
- Are you having difficulty doing your job because nobody appreciates how much you hurt? Yes or no.
- Do you think that you take too much medication? Yes or no.
- Do you sleep poorly and feel stressed most of the time? Yes or no.
- Do you get severe calf cramps after walking a certain distance, such as one block? Yes or no.
- Do you get up from bed and walk at night because your legs are restless? Yes or no.
- Do you suffer from frequent cramps at night in bed? Yes or no.
For questions 1 through 10, if you answered yes five or more times, you may have nerve-related pain and should see a doctor.
If you answered yes to questions 2, 4, 7, or 9, you should see a spine specialist.
If you answered yes to questions 11, 12, or 13, you may have joint back pain and should seek therapy.
If you answered yes to questions 14, 15, 16, or 17, you may have chronic pain syndrome and should be evaluated by a pain specialist or neurologist.
If you answered yes to question 18, have your doctor check your arteries for peripheral vascular disease, which is a serious condition.
If you answered yes to question 19, you may have restless leg syndrome, which is often inherited or caused by other medications and is readily treated.
If you answered yes to question 20, you may have benign cramps because of sev- eral causes, including vitamin D mineral deficiency. Discuss with your doctor.
Common Causes of Spinal Pain
Let’s begin by discussing common causes of spinal pain and learning to use this information to focus treatment. This classification system is adapted from the work of Robin McKenzie, PT. We will use this classification system to outline the origin and mechanism of spinal discomfort. These causes relate equally to the cervical, thoracic, and lumbar areas.
Spinal discomfort is most common in the third to fourth decade of life and is often associated with a lack of activity at a time when people should be the most active. McKenzie observed that after college, people focus on work, career, and family demands, leading to a decline in physical fitness and an increase in a flexion-biased lifestyle. The classification system is based on these two factors: diminished fitness and a flexion-biased lifestyle.
After you identify which classification is most relevant to your spinal symptoms, you can identify the starting point of your treatment plan, whether it is an additional medical workup, a change in medication, an injection, the start of a therapy program, or home remedy activities. These three categories make explaining, understanding, and addressing spinal discomfort easier. Just as each anatomical structure has a voice, your voice in the history and observations that you make tell a story. In listening to the story, your health care team can begin to identify the proper remedy.
Many different viewpoints can come onto play in categorizing spinal discomfort, depending on the person’s perspective. As you consider the following, try to analyze your discomfort to discover which classification best fits your signs and symptoms. Some clinicians, depending on their viewpoint, may find fault in categorizing symptoms this way, but many of us use this format successfully. The point is not to assume that these three categories encompass all scenarios of spinal pain.
Nevertheless, they are an excellent starting point in identifying most spinal pain issues, and from these we can choose a logical treatment path. After you identify which category best fits your discomfort, you’ll be able to use the information in chapters 3 through 7 to feel better.
The three primary classifications are postural syndrome, spinal derangement, and adaptive shortening.
What Is a Flexion-Biased Lifestyle?
Technological progress has resulted in many of us spending a large part of our day seated. When you sit, the mid to lower cervical spine and lumbar spine tend to adopt a flexed (bent forward) position. Sitting places the disc in a position of relatively uneven loading that puts more pressure on the front aspect and less on the back. Some joints are maintained in a compressed position, whereas some muscles are routinely kept shortened. Some muscles work too hard, and others work minimally, if at all.
For many, a typical day begins with a lengthy commute to work. That activity is followed by prolonged or frequent bouts of computer and desk work, a seated lunch, and then a return to the computer in the afternoon. The workday ends with a lengthy commute home. At home, a seated dinner is followed by television and computer work throughout the evening. Weekend activities may include using the computer, watching a ball game or movie, attending an event, or relaxing to read. Missing in this lifestyle are movement and fitness activities to offset the con- stant and repeated spinal flexion. This constant positioning into spinal flexion—a combination of work, home, and recreational positioning—makes up the flexion- biased lifestyle that is one of two main culprits in the onset of spinal discomfort.
Referred to as bent finger syndrome, postural syndrome describes pain associ- ated with a mechanical deformation of normal tissue that eventually produces discomfort. Mechanical deformation means that a prolonged strain on the tis- sues causes an end-of-range compression or a lengthened-position tension on a structure. Affecting the cervical, thoracic, and lumbar spine equally, spinal pain arising from a purely postural nature typically affects those in their 30s and younger. The pain is always local, never radiating, and never constant, and it is not produced with movement. The discomfort is intermittent, coming and going, often for periods at a time. Associated with a sedentary job, a lack of exercise, or constant unchanging positions, postural syndrome symptoms arise as the person actively moves into the faulty position, often unaware that she or he is doing so. The person often is not even aware that the positioning is the cause of the symptoms.
To illustrate postural syndrome, bend your index finger back until it begins to hurt. Notice where it hurts and what happens to the discomfort when you release the finger. The discomfort was local to the finger joint (nonradiating), occurred over time when a prolonged tension was applied in an end-range position (mechanical deformation in an end-of-range motion position), and eased when the pressure was released (intermittent discomfort). This discomfort fits the definition of postural syndrome pain because it comes and goes as the finger moves into and out of the position of pain elicited by the mechanical deformation of your pushing on it.
Now bend your index finger back again, but this time resist the force with some muscular effort at the finger. As one hand pushes on the finger, use the finger muscles to oppose the pressure, maintaining the finger in a neutral, at-rest position. Do you feel discomfort? Does the joint feel compressed, jammed, or tense? Likely not. The joint and surrounding tissues are happily in the middle of their available positions, far from tension or compression forces that cause the nerve fibers to signal pain. By using muscular effort to oppose the symptom-producing forces, you have found the key to the treatment of your spinal problem.
Postural syndrome can found in school-aged children, often girls, who stand with their knees hyperextended (locked fully straight). This stance creates irritation and pain of the tissues around the knee, lower back, and midthoracic and cervical spine. Add the weight of a backpack, and the spine becomes highly susceptible to discomfort.
Slumping in a chair for hours while reading or using a computer leaves adults sus- ceptible to postural-related pain in the midthoracic area. The paraspinals—long, thin muscles that span many spinal segments from the neck to the tailbone—gradually succumb to the force of gravity and lose their ability to hold you upright, especially after several hours in the poor position. As you slouch, those muscles are stretched (a mechanical deformation) and, along with other spinal structures, gradually lead to the perception of discomfort. As the overstretched muscles tire, knots develop, creating that low-grade, dull, gnawing ache, perhaps between the shoulder blades or across the neck. Ropey bands within the muscle contribute to chemical irritation of the nerve endings by diminishing blood flow and oxygen transport. The reaction of these bands and the symptoms that follow are the secondary results caused by postural syndrome. They are what cause you grief.
Other scenarios that may result in postural syndrome include holding the phone against your shoulder and ear; driving a delivery truck or commuting a long way; prolonged standing to cook, clean, or shop; typing or reading; or performing desk-related job activities. In each case, the spinal pain sufferer can move into and fully out of the symptom-provoking position but in most cases does not because he or she is not even aware that the position is causing the discomfort in the first place.
Common spinal diagnoses associated with postural syndrome include cervical, thoracic, or lumbar strain; mechanical low back pain; headaches; and muscle strain. Given the mechanism of the symptoms, the treatment for postural syndrome clearly is exercise, specifically exercises designed to strengthen the muscles needed to hold you in the proper, non-symptom-producing position. Not that biking, jogging, and softball won’t help.
To help recognize the irritating factor, pay attention to your positioning during the day and try to correlate it to the onset of your discomfort. After you identify the likely cause, you can try to change that position and start strengthening activities to offset the position.
Is It Postural Syndrome?
To know whether a postural syndrome treatment approach is right for you, ask yourself these questions:
- Do you spend hours at a time on the same task in the same position every day?
- Do you have a sedentary job? A sedentary lifestyle?
- Are you 30 years old or younger?
- Does the discomfort come and go and vary in intensity and frequency? Does it get better after you change positions or exercise?
- Is the discomfort confined to the back? Is it annoying or gnawing but not urgent or intense? Is it nonradiating (that is, the pain doesn’t move down the arm or leg)?
For those with discomfort in the cervical area, postural syndrome commonly involves the muscles of the midback and shoulder blades (figure 1.2) and the short neck flexors along the front of the neck. For those with lower back symptoms, strengthening the lower abdominals, gluteal (buttock) muscles, and lateral hip muscles is of primary importance. Just as supporting your finger as you pushed it back eliminated discomfort, the treatment for postural syndrome pain should be to strengthen the muscles that support the spine and learn to correct the faulty positions that are causing the discomfort.
What McKenzie called derangement syndrome does not refer literally to your state of mind, although the discomfort may make you figuratively crazy. Instead, the term refers to a condition of the spinal disc. Spinal disc bulges, herniations, and annular tears are common conditions that affect the spinal discs. Generally, about one-third of disc problems occur in the cervical spine, about two-thirds in the lumbar spine, and a small percentage (roughly 2 percent) in the thoracic area. More prevalent in males than females, disc dysfunction is most common in the 25- to 50-year-old age group and is associated with a flexion-biased lifestyle. Onset of most discogenic conditions is usually nontraumatic, occurring gradually over time instead of resulting from a one-time traumatic event such as a fall or car accident. Although the precipitating event may have been writing a lengthy report, working in the yard over the week- end, lifting a baby from the crib, or bending repeatedly while sorting files at work, the origin of the problem likely had been brewing for many months, even years.
Discogenic-related symptoms follow a classic presentation. Their voice is clear and seldom garbled. Symptoms of discogenic origin are episodic, recurring over time, each episode a little more severe and longer lasting than the prior one. Typi- cally, symptoms begin with mild stiffness and ache and resolve quickly and without lasting deficit. As each episode passes, the discomfort becomes more debilitating until treatment is sought.
Symptoms in the cervical area often include painful stiffness when turning the head. Discomfort may or may not radiate into the arm. A deep, fist-size ache between the shoulder blades, known as a Cloward’s sign, is a common complaint. Often, looking down and turning the head are limited. Jolting or jarring activities such as driving on a bumpy road are painful.
When pain is in the lumbar area, sitting and bending worsen the discomfort but walking generally eases the pain. Lying on the side or back with the feet up also often helps ease pain because these positions generate the lowest intradiscal pressure.
Forward bending produces symptoms and is often the most difficult movement to do. Coughing and sneezing are often painful, and discomfort increases when moving from sitting to standing. Usually, symptoms are worse in the morning, ease as the day progresses, and flare up again by the end of the day.
In all cases, symptoms may be in the center of the spine (central) or off to one side (unilateral), or they may radiate to the arm or leg (peripheral or referred). Generally, if the discomfort moves away from the spine or farther down the arm or leg, the condition is considered to have worsened. If the symptoms move more centrally toward the spine, it is considered a sign of healing. In fact, you may experience a more severe and noticeable pain closer to the spine as the symptoms in your arm or leg abate. This centralization of symptoms, although more uncomfortable in one spot, is a positive part of the healing process.
For those with derangement syndrome, activities that increase flexion pressure tend to worsen symptoms, and activities that lessen flexion pressure tend to ease symptoms. Lying on your side lessens disc pressure and generally feels good. Sitting, bending, and leaning over increase disc pressure and generally are not easily tolerated.
To understand the mechanism of discogenic pathology, visualize a jelly donut, which has many characteristics similar to those of a spinal disc. In both items, a viscous, gel-like center is surrounded by a firm but moveable outer layer. If you grab a donut and press evenly on the top and bottom, the donut will not deform much. If you push down on the front part of the donut, the jelly in the center likely will be forced to the back of the donut, away from the pressure. If the donut has a small hole or crack, the jelly may eventually squeeze out through the crack, possibly spill- ing out along the side. Jelly that simply presses against the outer edges of the donut would be analogous to what your doctor refers to as a bulge. Jelly that actually oozes out from the donut would be similar to what your doctor would call a herniation.
The point is that the central nucleus responds to asymmetrical pressure placed on the disc. As you bend forward, pressure is placed on the nucleus toward the back. As you bend backward, pressure is placed on the nucleus in a more forward direc- tion. The posterior structures are the most innervated with pain fibers. Therefore, with repeated and prolonged bending, pressure on the disc continually forces the nucleus toward the posterior. As fissures develop within the annular bands, the center material migrates toward the back of the disc where the more pain sensitive structures are located. These include the posterior longitudinal ligament, spinal nerve roots, and spinal cord. As the disc material moves out, the disc height may gradually decrease, setting up conditions such as spinal stenosis, degenerative disc disease, and joint arthropathy. These conditions are secondary to disc derangement and occur later in life, generally in the early 50s or later.
An MRI result that shows a disc bulge implies that the annular wall is intact, which is a good thing because the hydrostatic mechanism (pressure gradient) within the disc is intact. Much like a water balloon, it may change its shape when it is pressed on, but the water does not spill out. The disc often responds to treatments such as training in proper body mechanics to minimize flexion pressures and performing repeated movements that use back bending to offset the flexion pressure. Positions and movements of the spinal column influence the position of the nucleus either adversely or as a therapeutic intervention.
An MRI that indicates a herniation or rupture implies that the disc wall has been breached and that the center material is extruding. The hydrostatic mechanism is no longer intact. Interventions that work on the concept of pressure are not as effective. Fortunately, other treatment options are effective, such as exercises, stretching, and localized ice to address inflammation.
Is It Derangement Syndrome?
To know whether a derangement syndrome treatment approach is right for you, ask yourself these questions:
- Are you 25 to 50 years old?
- Do you spend most of your week sitting or bending forward?
- Is the discomfort episodic, each time stronger, more limiting, and longer lasting than the prior bout?
- Do you feel better as the day progresses but worse in the morning and by the end of the day?
- Does extending the neck or lower back feel good but looking down or bending forward hurt?
- Does it hurt more when you cough or sneeze? When you move from sitting to standing? When you bend to brush your teeth, wash your face, slip on your socks and shoes, or get into your car?
Symptoms of a discogenic origin generally elicit a yes response to most of these questions.
Unlike postural syndrome, adaptive shortening implies an inability to move actively out of a pain-producing position. Over time, the connective tissue and muscles become shortened and tight, the result of prolonged, repeated positioning in one posture without adequate stretching out of that posture. The key characteristic in this group is a functional loss of motion—an inability to move into a more comfortable position because a shortness of some tissue is preventing that from happening. You’re not aware of it, of course, because the body does a good job of finding alternative motions to accomplish what you want it to do. Regardless, the shortness of some tissues creates imbalances that cause pain over time.
Affecting the cervical, thoracic, and lumbar spine equally, spinal pain arising from adaptive shortening typically occurs to those in their 30s and older. The condition is most prevalent in those over 50 years old. People with a generally sedentary lifestyle and those who tend to maintain the same position for most of the day are susceptible, especially as they age. Symptoms may be local or radiating, sometimes intense, and may seem urgent, especially with diagnoses of radiculopathy or sciatica. Symptoms usually are not constant and ease with a change of position. Complaints may be described as annoying, and functional limitations are present, especially when walking or looking or reaching up. These patients tend to present with diagnoses of spinal stenosis, cervical or lumbar radiculopathy, sciatica, degenerative joint disease, or neck or low back pain. The stiffening of the tissues with age and the shortening of the tissues attributed to a flexion-biased lifestyle often are the roots of the problem.
A normal lifestyle can feature an abundance of one type of activity, such as sitting, at the expense of another, such as exercise. For example, consider an accountant, secretary, truck driver, and airline pilot. Each has a job that requires a lot of sitting. If constant sitting is unopposed by stretching, over time the hip flexors in the front of the hips, calves, lower back connective tissues, upper chest, suboccipitals at the base of the skull, and some of the front neck muscles shorten. The head tends to jut forward, and the shoulder blades round toward the front. The midback rounds as well, and the lower back becomes excessively lordotic (bent back). The tight lower leg muscles limit hip and ankle motion so that when walking the pelvic girdle tilts forward and the spine moves into an excessively lordotic position. Especially during walking, the shortness of muscle length leads to added shear and torsion stresses through the spine that lead to degenerative joint disease over time.
Consider a postal carrier, airline mechanic, warehouse supervisor, and car sales- man. Each has a job that entails a lot of standing or walking. If this standing and walking is repeated and unopposed by stretching, over time such people will develop movement limitations similar to those who sit all the time, only in the opposite direction. This is the process by which adaptive shortening occurs.
Without offsetting the constant or excessive positions assumed during the week, the body adapts to a new normal and shortens to fit that position. Discomfort is the result when people attempt activities that place tension on those shortened structures when they move out of the usual position. For those who sit, activities involving standing, walking, shopping, cooking, cleaning, and recreation such as golf or tennis—activities that require extension—tend to produce symptoms. For those who stand and walk all week, activities that require bending such as garden- ing, reading, painting, or computer use seem to elicit symptoms. As the adaptively shortened tissues are stretched, discomfort is felt.
For those with postural syndrome, strengthening is paramount; for those with adaptive shortening, stretching is the remedy. By elongating the shortened tissues, you relieve the cause of the symptoms. As a result, you can use movement patterns that are more natural, use movement options that are more normal, and engage in more day-to-day activities without discomfort.
Those in this category of spinal pain are older than those in the postural group. Connective tissue is made up in part of proteins, of which elastin is a component. The elastin gives the tissue a springy nature, allowing it to elongate or return to its resting shape as necessary. Elastin gives your skin the bounce back characteristic that you see when you pull or push on it. As we age, elastin is gradually replaced with a thicker, more fibrous tissue that is less malleable and less giving with movement.
This new tissue doesn’t stretch as easily. When it is repeatedly placed in shortened positions such as when you sit all day or stand and reach to the right all day, the tissue tends to conform more readily to those positions. Repeated positioning in conjunction with tissues that become less elastic and more fibrous as we age sets the groundwork for adaptive shortening. Through this process adaptive shortness is created.
Is It Adaptive Shortening Syndrome?
To know whether an adaptive shortening treatment approach is right for you, ask yourself these questions:
- Do you spend hours at a time on the same task in the same position each day?
- Do you have a sedentary job? A sedentary lifestyle?
- Are you 50 years old or older? Adaptive shortening is more common in those over 50, although it can show up in those 30 and older.
- Does the pain vary in intensity? Does it feel better in certain positions but worse when you change positions?
- Does looking down or turning your head cause pain in your neck? Are your shoulder blades rounded forward and your upper back curved (hunched) forward?
- Is your spine often overly extended (bent back) during long parts of your day? • When you walk, do you notice that your spine rotates (twists) more than the spines of others?
- When you bend forward to touch the floor, is your range of motion less when your knees are locked straight and more when your knees are slightly bent?
- Is the pain localized to your back or neck, or does it radiate into the arm or leg?
- Does stretching ease the pain but engaging in activities such as sports or work aggravate your symptoms
Watch others walk and then assess your own gait. If you have adaptive shortening, you may notice that your lower back seems to rotate more than the back of others. This occurs because the front of your hips and back of your lower legs are likely very tight. When you lack motion in one plane, the body compensates by adding movement in another plane. As you attempt to move in a forward direction, the tightness creates a movement torque into rotation of the lower back, thereby causing torsion forces. These forces lead to many of the symptoms discussed throughout this article. If you have adaptive shortening, your ability to bend forward and touch the floor will be less with your knees locked straight and better when they are slightly bent. In either case, you should notice that your spine doesn’t seem to move much. Most of the motion comes by hinging through your hips or upper back, not your lower back.
By analyzing your common postures and positions during the day, you can begin to identify what may be staying shortened, thereby understanding what needs to be stretched. The stretches covered in chapter 4 often go a long way in mitigating discomfort. The key is to stay consistent with stretching because often the dynam- ics of your day will not change significantly. The advantage of a program that relies on stretching for improvement is that stretching is easy to do. It doesn’t require a special trip to the gym, and it can be done in several small bouts during the day, often while you are doing something else. You don’t need to find 15 or 20 minutes a day to exercise. For example, you can easily stretch the backs of your lower legs while standing and talking to a friend on the phone or stretch the front of your chest on a door frame as you wait for the water to boil or the microwave to chime.