An Overview 

Each vertebra is joined to its neighbour by facet joints which are located between the knobbly bones you can feel (or see) running the length of your back.  They help control movement and support the weight of the body.  There are two facet joints at every level.  They are fairly flat, lined with cartilage and surrounded by a fibrous capsule which secretes synovial fluid, all these features allowing ease of movement with no friction.  Unfortunately, over time or through injury, changes can occur in these joints, leading sometimes to pain. 

Back pain is often felt to one side and behaviour of the spine is unpredictable.

Symptoms 

Although it is very difficult to make an exact diagnosis without the benefit of an CT scan or XRay, an experienced therapist can make a reasonable assessment given the correct information (not always easy).  Some of the common symptoms of facet joint problems are:- 

• Pain to one side of the spine, especially if you bend to that side.
• Pain first thing in the morning.
• Pain and stiffness after long periods of standing or sitting.
• Pain from lumbar facet joints may radiate into the buttocks and down the back of the legs, but would probably stop above the knee, unlike pain from a herniated disc which could go all the way to the foot.
• Similarly with the upper spine: the pain may be felt in the neck, shoulders and upper back without radiating through the arms.
• Episodes tend to be intermittent and unpredictable, eg, you might bend over to pick something up one day and it seems to suddenly lock.
• Leaning backwards will normally cause more problems than leaning forward. 

Treatment

• Injections into the joint:  This can be used as a way to determine whether or not it is a problem with the facet joint.  If it is, the pain will be relieved by a combination of anaesthetic and cortisone.  If successful, the patient will normally be allowed up to 3.
• Anti inflammatory drugs
• Heat or cold pads
• Manipulation:  A chiropractor or physiotherapist may be able to release and loosen the joint.
• Restraining collar:  If the problem is in the neck of course.
• Modifying lifestyle:  Take care with high impact exercise; don’t sit for long periods or check your chair; check your lifting technique; get moving – walking, cycling, swimming are all good forms of exercise; stretches are very good; watch your posture.  PILATES is the ideal form of exercise to strengthen the core and back muscles, but also help mobilise the spine.  If you have a facet joint problem, you should be doing some Pilates everyday and the easiest, most convenient and cost effective way to do this is with the Back Care Series Pilates download - scroll down to the end of the page.

Many people come to class complaining of discomfort or pain in their legs, thinking that they have pulled or strained a muscle and are surprised to learn that it may well be a back problem which is causing referred pain.  Most of us have either had sciatica or understand the idea that it is something to do with the back, not a pulled muscle in the buttock.  With a herniated disc, for example, this pain can travel right the way down the back of the leg and originates from the bulging disc irritating the sciatic nerve.  The same is true of other nerves: there are nerves all over the body and depending on which one is being irritated will depend on the area you will feel this referred pain. 

Spinal Cord and Nerves 

The spinal cord comes from the brain and is housed by the spinal canal which helps protect this delicate organ, together with the cerebral spinal fluid.  The nerves branch off the cord and exit through the foramen, gaps at the side of each vertebra, making their way to parts of the body and organs, transmitting information to and from the brain.  The cord and brain make up the central nervous system, whilst the nerves connecting the cord to the body make up the peripheral nervous system.  The nervous system is responsible for all movement, function and sensation of the body.  The spinal cord ends roughly around the first couple of lumbar vertebrae and the rest of the nerves hang down in a bundle, like a horse’s tail (cauda equina).  Each  nerve has a protective sheath around it, extending just beyond the spine, but any changes in the facet joint or the disc can cause contact, causing the nerve to become inflamed.  This causes pain, for example, sciatica. 

The Torso Muscles 

In Pilates, these muscles are sometimes referred to as the corset muscles because this is exactly the way in which they act, running vertically, laterally and diagonally.  Without these muscles, the spine would collapse in a heap.  Research is ongoing as to how best to exercise these muscles, but one thing everyone agrees on is the importance of strengthening them and keeping them strong.  The major muscles involved make up what is known as the core:-

Avoid back problems: Pilates will create a girdle of strength by toning the core & torso muscles

• Rectus Abdominus:  These are the “six pack” muscles, clearly visible in mostly male athletes, running down the centre of the body from breast bone to pubic bone.  They can separate during pregnancy.  A good example of a Pilates exercise to strengthen them would be the roll up.  Their role is to support the spine when flexing (bending)
• Obliques:  These muscles wrap themselves diagonally around the body – external around the ribs, internal roughly from hip to pubic bone.  The side planks work these muscles very effectively in Pilates.  They offer support when rotating (twisting).
• Transversus Abdominus (TA):  The deepest layer of muscle, offering stability to the spine, a bit like a weight belt and running laterally.  In Pilates, these are referred to as the core muscles and great emphasis is placed on strengthening these muscles – 100, single leg stretch, front plank – and using them in our daily lives.
• Pelvic Floor:  Running like a hammock from the pubic bone to the tail bone, strong pelvic floor muscles keep the uterus, intestines and bladder in place.  They work with the TA and MS in a co-contraction to support the pelvis and spine.  Pelvic floor and exercises
• Multifidus Spinae (MS):  The most important of the spinal muscles, a deep layer running either side of the spine and very much in control during bending, almost pulling each vertebra back up and restacking.  Works very closely with transversus. 

Strong abdominal muscles, together with a co-contraction with the back muscles work to keep the spine upright.  A strong contraction during bending offers the lumbar area good support (a bit like filling up a space as you suck back the abdomen) and allows the ligaments to do their job in stabilising the spine.   During bending, it is essential that the muscles of the torso, including the back muscles, are contracted first to stabilise the spine and control the movement.    

So you see, it is essential to strengthen the torso muscles and use them during movement to avoid back problems.  Poor posture and a sedentary lifestyle have contributed to a breakdown in the corset muscles and this is often the first stage of a back problem.  The featured video (also here http://www.youtube.com/watch?v=eZOOHQzos8s) this week shows the Twister which targets all the core muscles, but if you haven’t done Pilates before, please do not attempt it.  Download the Beginners Pilates course and learn safely from the very beginning.

A long post, I know, but there is a lot of useful information here.  Our free video this week is an excerpt taken from our Back Care Series of 3 videos to help you through each stage of back pain and help you maintain a healthy spine.

The spine is hooked together by a series of facet joints, the upper pair sitting in the lower pair, allowing for freedom of movement of the spine.  Just like any other joints, they are susceptible to wear and tear. As well as the significant role of the discs, the joint capsules play a large part in protecting the facet joints and can easily become inflamed which could lead to pressure on nearby nerves, causing pain.  The surrounding muscles may then contract to further protect the back, causing more pain.  An early diagnosis is extremely useful as the first stages in facet joint breakdown are more to do with inflammation, nerves and muscle spasm rather than the bony joint itself.  A good therapist can feel the problem with the hands and using imaging in the early stages as a form of diagnosis is not particularly useful.  The later stages of bony chafing can lead to lack of mobility and arthritis, so although these early stages can be very uncomfortable, once a diagnosis has been made, there is a lot you can do for yourself to prevent the situation getting any worse. 

CAUSES 

Degeneration of Discs 

The stiffening and narrowing of discs is a natural part of aging.  They start to lose their sponginess, and therefore their protective qualities.  Apart from aging, this can also be as a consequence of a trauma, a lack of suitable exercise to enable the discs to squeeze out and draw in fluids or poor posture.  Whatever the reason, the result is the same:  without the cushioning, the top facet joints press hard into the lower joints, causing the capsular fibres to tear and build scar tissue, reducing movement.  The joint will secrete more synovial fluid to aid movement, but this leads to inflammation and the surrounding nerves may become irritated.  The multifidus muscle may then go into spasm and further reduce the movement of the joint. 

Poor Posture 

Lordosis, where there is an excessive curve of the lower back and a forward tilt of the pelvis, and swayback, where the pelvis is shunted forward of the plumb line (see the series on posture): both postures will put tremendous strain on the lumbo-sacral facet joints.  Think of them as becoming jammed and grinding together.  Facet joint trouble can occur further up the spine:  think of postures with a forward head and the effect this has on the neck; occupations and poor postural habits where the shoulders are hunched up and again the head is forced forward.  

Inequalities 

Most of us will have noticed differences in the two sides of the body.  Although these differences may be more pronounced in, say, sportsmen, where there is constant repetition from one side of the body both frequently and intensely (think of golf where the ball is struck front the same side every time with a twist in the swing), the rest of us will have them to a lesser degree.  Many of us may have a leg that is slightly shorter which will cause muscle imbalance in the pelvis and put a strain of the facet joints, amongst other problems. 

Weak Abdominal Muscles 

If the abdominal muscles are weak, they are likely to be stretched and lengthened, so rather than the pelvis being held in a neutral position, it will end up tipping forward, creating too much of a hollow in the lower back, causing the facet joints to jam together.  This is where Pilates can be a tremendous help.

Strengthening the abdominal muscles will stabilise the spine and relieve back pain

Symptoms 

Facet joints can be stiff for years without causing any pain, but it can become a problem quite suddenly, perhaps from making some awkward movement.  You might experience a momentary sharp pain and possibly hear a click or tear, but apart from being a little tender, you will think nothing of it.  It is later on that day or when you wake up the next morning that you will experience a stabbing pain in one side of your back, often accompanied by waves of  pain through the buttock and down the leg, particularly when you put your weight on it.  This referred pain is due to the nerve being pinched by the inflamed capsule and irritation from fluids seeping from the wall.  Any change in position can set the pain off down the leg and the muscles will often contract to reduce movement and protect your back.  Your back will often feel stiff in the mornings or after sitting or standing in one position for long periods of time.  Movement is just what your back needs and with any luck, possibly with the aid of anti-inflammatories and muscle relaxants, this stage will pass quite quickly.   You can help immensly by using certain Pilates exercises and the first video of the Back Care Series from our Pilates video downloads is specifically designed to help you through this stage.  It gives way to a more localised area of pain to one side of the spine.

Treatment 

The first step would be to reduce the inflammation.  Rocking the knees to the chest will help, as will roll ups, if you are able.  If you are following the Pilates courses, you will know what these entail.  We often draw the knees to the chest to release the lower back after core strength exercises.  Reverse curls, where you draw your knees to your chest by using your abdominal muscles rather than momentum, will do if full roll ups are too much for you.  The cat stretch is also a great way of increasing circulation, opening and closing the joint.  Roll down to stretch out the joints and later, the saw to give a diagonal release, are all key exercises.

Also known as slipped or bulging disc, this is actually much less common than we are led to believe: only about 5% of back problems are because of a prolapsed disc.  The term “slipped disc” is also misleading as this would lead us to believe that the whole disc slips out of place, whereas it is actually more of a bulge in the disc wall.  The pain can be intense, but it is not the disc that is painful, but more the pressure it puts on areas around it, such as the nerves.  Some 20% of the population under 60 years of age have bulging disc with no symptoms whatsoever, so a disc merely bulging is not necessarily going to be painful.  Another myth is that you can suddenly “slip a disc”: for a disc to get to the stage when part of the wall bulges, it is clearly the result of years of degeneration resulting in this weakening.  If other parts of your back are not working as they should, this will gradually put pressure on areas above and below, increasing the chances of a breakdown of the disc wall. 

Part of the problem could be that if there is any pain in the back, the muscles will tighten up as a protective measure and this will cause compression.  As more and more pressure is put on that segment involved, it will squeeze the disc, causing it to bulge.  The generally held opinion that a sudden movement will cause a prolapsed disc would appear to be quite wrong and it is more the result of a pre-existing problem, whether you were aware of it or not.

The only real way of being sure of a correct diagnosis is to have an MRI scan which can be hard to get on the NHS unless you can bear the wait, often over a month or so.   The discs are behind the facet joints which are normally visible knobbly bits down the middle of your back, so it would be hard to feel a bulging disc. 

“I was referred for Pilates after a slipped disc, so when I started I was not able to move my back in all directions. After a few months, I was able to do not only what I could do before the slipped disc, but actually more." Laura O, SW19, aged 46

Causes 

Compression seems to be a key factor, resulting in stiff links and weakening the disc involved so that a relatively simple movement such as dragging the wheelie bin up over the step or moving a piece of furniture could cause the bulge in the disc.  Poor posture or sitting slumped for long periods of time can cause this.  Heavy work, such as lifting incorrectly can also have an impact as this forward bending action puts a tremendous strain on the disc, as does the twisting action normally involved with lifting.  As we get older, the discs degenerate and lifestyle choices, e.g. poor nutrition and little exercise, will increase the chances of any back problem. 

Symptoms 

You may have been aware of an achy back for some time, but not so troublesome as to need to do anything about it.  As described above, you may do something which at the time wouldn’t cause any particular concern, just a twinge somewhere in the back.  Over a few days, the pain and tightness in the back will start to increase and then you will start to feel it deep inside the buttock, moving down your leg like cramp or a pulled muscle.  The tightness can become so strong that you may have difficulty getting your heel to the floor and the pain can be intense.  I’ve heard it described like a red hot poker, reducing movement to a hobble and making forward bending impossible.  Because of the pressure sitting puts on the spine, this is often not possible for any length of time.  You just can’t get comfortable.

The pain is most likely to come from the bulge pressing on the nerves.  It also may be as a result of the disc fluid escaping and seeping out onto the nerves.  They become inflamed and sensitive causing the agonising pain, numbness or weakness in the affected leg.  This acute phase usually passes with or without help, leaving you feeling very stiff with pain from time to time.

Far more serious is when the back of the disc presses against the cauda equina, the bundle of nerves at the end of the thoracic area of the spine.  This can cause loss of control of the bowel or bladder and can cause impotence and requires immediate medical intervention. 

Treatment 

Around 50% of surgery to help correct this problem is unsuccessful, leaving the patient if not in a worse state, certainly no better.  So the best way round it is to help yourself.  In the most acute stage when you won’t be inclined to do anything because of the pain, there are four things you really should do whilst waiting to see a therapist:-

1. Take anti-inflammatory medication, preferably something fairly strong from your doctor, but be consistent.  Don’t take a couple and then not bother for a day or so.
2. Sleep in a foetal position with a pillow between your knees.
3. Lie on your back holding onto the back of the thighs with the knees bent, shoulder width apart.  Draw your knees towards your shoulders on the exhalation, release on the inhalation..  This will reduce the compression and should be repeated 10 times.  Take a short rest, then do this again another 4 or 5 times. You won’t be able to do much anyway, so rest if you can, finding a comfortable position and repeat this exercise as often as you can (every hour preferably) until the leg pain is reduced.
4. You need to strengthen your abdominal muscles to release the pressure on your back.  A level 1 Pilates single leg stretch is a good place to start: find neutral position with the knees bent, feet on the floor.  As you exhale, raise your upper body, resting your head in your hands and keep it there.  Each time you exhale, raise a foot off the ground and take it back to the floor as you inhale.  Alternate.  Repeat up to 10 sets and do this exercise every time you repeat 3 above.
5. Start a Pilates course as soon as possible.  You can download the whole Beginners course from this site – just click on Downloads/Pilates.  Look out for the Complete Back Care course coming soon. 

You need to avoid sitting or standing for too long in the same position and you really should get out and walk, just short 10 minute walks a couple of times a day, building up the duration as you feel more able.  Always be mindful of your posture and use the abdominal muscles to take the pressure off your back.

There are many problems that can occur with the back, causing anything from general stiffness to acute pain, anywhere from a particular spot in the spine to referred pain, such as sciatica.  Unless you have suffered a trauma or have grown up with a defect of the spine, it is not always easy to find out what exactly the problem could be.  A trip to your GP rarely gets to the root of it and you could wait up to 2 months to see a physiotherapist on the NHS.  Seeing a therapist costs, so although this may be necessary at first, the last thing you want is to rely of them long term.  Pilates is the single most effective way for long term relief from back pain.  See this weeks video.

Symptoms

Most back problems develop gradually, even though it can sometimes feel as though a certain action caused it there and then.  If you think carefully, you will probably realise that your back has been uncomfortable for some time, but a quick stretch, maybe a bit of a backbend will ease the stiff feeling.  This stage could go on for years, just a low level achy feeling, but not painful as such.  This can change suddenly and completely take you by surprise.  It could be something as trivial as pulling a heavy wheelie bin up over a kerb without thinking about your technique or twisting and lifting something.  The pain can be extreme, right across the centre of your back.  Whatever position you take – sitting, standing, lying down – you just can’t get comfortable.  Your back feels very fragile and any unexpected movement can cause intense soreness.  You will probably notice that although it was painful at the point of injury, it gets steadily worse as that area of the spine becomes inflamed.  It is your body’s way of trying to prevent you from making the matter worse by moving around.

Things will gradually settle down to a more bearable soreness and discomfort with the occasional flare-up from time to time.  This phase gives way to a deep, achy stiffness of the lower back.  Getting in and out of a car or standing up after sitting for a while can make you feel like a pensioner you’re so stiff.  Bending backwards may feel good, but bending forward is awkward and uncomfortable.

Bending backward can help relieve stiffness and pain at first

Treatment

When your back is very painful, you will be inclined to do nothing.  Rest for the first 48 hours together with a course of ibuprofen and short walks should help.  Even when the initial acute pain has eased off, you will be reluctant to make any movement which could set it off again.  However, it is important to get the stiff spine moving again.  Simply lying on your back, holding behind the thighs with the knees apart and drawing your knees towards your shoulders a few times will gradually stretch out the lower back.  In Pilates, Rolling like a Ball is a good exercise so that you start to use your abdominal muscles as well to control the movement.  Squatting, dropping your bottom right down to the floor is quite a tricky movement for many, but also decompresses the lower spine.  If you hold on to something to stop yourself from falling backwards and maybe have a telephone directory under the heels to start with, you will soon get the hang of it.  The Cat Stretch is an excellent exercise to stretch and gently strengthen the abdominals and spine extensors.   When you are in pain or your back feels uncomfortable, the last thing you will think about is engaging your core muscles and pulling you abdomen right in, but this is essential, because without this, your back has very little support.  (See the blog on Core Stability)

Did you know that 90% of us will suffer from back problems at some point in our lives?

60% will be sub-acute or chronic and at least half of these cases will be caused by poor posture. The effects of these alarming statistics are far-reaching as the following facts show:-

• 11 million working days are lost each year.
• Bad backs are the main reason for time off work.
• Last year 200,000 women took time off work to recover from a back problem.
• The cost to British industry is around a staggering £5 billion a year.
• The cost to the NHS is estimated to be £480 million.

So what are the main causes of back problems, apart from abnormalities in the spine (eg, a scoliosis), a trauma (eg, car accident) or the natural ageing process (degeneration of discs, osteoporosis, arthritis)?

Many back problems are caused by poor posture & lifestyle

Without getting too clinical and scientific, the following are 5 reasons for spinal complications:-

1. Poor posture: The spine needs to be in a good neutral position so as not to create imbalances.
2. Carrying too much body weight: Imagine the strain on your back, having to carry you around and if you are overweight, you are probably unfit, which brings us to our next point;
3. Poor health and fitness levels: There is no direct blood supply to the discs and they depend on movement to push oxygen and nutrients to them. Smoking will restrict the oxygen supply. A poor diet will restrict the nutrition available. Short/weak muscles, lack of flexibility and immobile joints (spine especially) will have a direct effect on the spine.
4. Being in one position too long can cause problems: Sitting (consider your driving position as well), standing (body on one leg, core muscles relaxed) and bending incorrectly will all take their toll. Check your mattress too.
5. There seems to be a link between depression and chronic back pain.

It is now widely acknowledged that pilates and yoga can help prevent back problems and aid recovery. Doctors and therapists are recommending pilates in particular to their patients for these reasons.

“If at the age of 30 you are stiff and out of shape you are old.  If at the age of 60 you are supple and strong then you are young“.

Joseph Pilates

Pilates is an extremely safe and effective exercise programme. It focuses on the core postural muscles which help keep the spine correctly aligned as well as working on the strength, mobility and flexibility of the whole body.  As a form of meditation it will focus the mind, leaving you feeling less stressed and improving your feelings of wellbeing.  Pilates works on correcting muscle imbalances and reduces the risk of back problems. 

It was developed by Joseph Pilates at the beginning of the 1900’s. Joseph Pilates was born in Germany in 1880 and throughout his childhood, he was plagued by ill health. To make himself physically stronger, he took up body-building and various other sports, including gymnastics and diving. He later moved to England, but when World War I broke out he was interned on the Isle of Man. Whilst working as a hospital orderly, he came into contact with many war casualties and it was then that he started to develop his Pilates system as a way of helping them.

The Teaser

He believed that imbalances in the body and habitual patterns of movement cause injuries. He saw the links between weak areas of the body and overcompensation by other parts of the body, so he set about creating a programme based on re-education and realignment of the body. He moved to New York in 1926 and set up an exercise studio and Pilates soon became a favourite form of exercise for dancers and athletes.

In recent years it has become one of the most popular forms of exercise, not only improving the shape of the body and posture, but for a whole host of other health benefits too. It is recommended by doctors and back care specialists as a form of rehab following back problems as well as a way of preventing them.

Sportsmen are using this system of exercise more and more as a way of improving their core strength and balance. Pilates requires a great deal of concentration, precision, control and fluidity. It was designed to create a healthy body, a healthy mind and a healthy life. The Pilates philosophy is all about training the mind and body to work together towards the goal of overall fitness. It is all about quality, not quantity.