Disc degeneration and spondylosis of vertebrae are associated with aging and will reduce mobility of the spine.

These changes involve functional limitations and increase susceptibility to pain, especially with forward bending. Mobility can be improved in the vertebral joints, just as in the extremities, with stretching exercises. Exercise would be easy if stiffening developed at the same pace throughout the spine without symptoms of pain. However, it is more likely joint mobility will vary between vertebrae and stretching will easily be directed towards those joints which are more flexible. There may even be hypermobility, and thus stretching will not affect the stiff joints. Specific mobilization and a special exercise progranune are necessary in order to improve mobility in the required areas of the spine and to avoid making the condition worse in joints with excessive laxity. Limited joint mobility will lead to degeneration of the deep intervertebral muscles and a reduction in strength of the back muscles. Muscle tissue may be replaced by tougher, less flexible fibrin and fat tissue. This can only be prevented by restoring mobility with active exercising at an early stage of the back disorder. Tight hamstrings, iliopsoas, piriformiS, quadriceps, quadratus lumborum and paraspinal muscles are usually involved in back pain as possible sources, or as complications due to pain. In physiotherapy attention is often focused on stretching the hamstrings in treatment of the lower legs. However, the iliopsoas muscle is of particular importance to back function. The iliopsoas is commonly involved in back pain and it is also often the actual cause of back and hip pain. Tension in the iliopsoas muscle may likewise be caused by pain in the lower abdomen, lower back and hip area. It may also tighten under static loading during sustained hip flexion or due to strain wound after hyperextension of the hip joint. Referred pain from trigger points in the iliopsoas muscle can affect the lower abdomen, hip and back. Tightness in the iliopsoas muscle will cause straightening of the lumbar spine, which puts more loading on the discs as loading moves off the facet joints onto them. Disc function and metabolism is disturbed in the lumbar spine due to increase of intradiscal pressure. Discs become dehydrated, which causes further stiffening of the back. Hamstring muscle tightness will cause the pelvis to tilt

backwards and normal lumbar lordosis will diminish, become straight or turn to kyphosis, which will decrease mobility. Furthermore it will lead to an abnormal posture in which the straight lumbar spine is accompanied for by bending the thoracic spine, shoulders and head forwards. Straightened lumbar spine and excessive kyphosis in the thoracic spine place an increased pressure on the front part of the lumbar vertebrae and, particularly, the inferior spinal discs. It will stretch intervertebral and iliolumbar ligaments and the posterior side of discs. The back's ability to withstand loading weakens. This process will be accentuated due to degenerative changes with advanced age, which also decrease mobility of the back. Stress on the spine may become too great and cause back problems. This postural syndrome is a common cause of chronic back pain. It becomes even more evident if work and leisure activities require repetition of forward bending or a statically held forward bent position. Both frequently repeated and chronic back pain often involves two problems: improper posture and disc degeneration. Active stretching to restore and preserve back mobility as well as exercise to restore normal posture are important before stiffening changes in the spine become permanent contracture. Symptoms of pain in the lumbar spine of the young and middle aged will often be due to instability as well. Active stretching exercises, which are often advised for treatment for a stiff back, may increase instability and pain. Treatments should preferably be designed to increase stability to support joints by improving muscle tone and strength. Age is not necessarily a direct indication as to whether or not stiffness or hypermobility is the problem. Even school age children may have back stiffness and people in advanced age may have hypermobility, although these cases diverge from the norm in the majority of people. It is also possible for one individual to have hypomobility in some joints while having hypermobility in others. Stretching routines should be based on clinical examination in which each joint is tested for mobility. Examination of the entire spine at once with tests including only gross movements is not sufficient to reveal variations in mobility between each articulation. It may give normal results, although half of the moving segments would be hypermobile and the other half

hypomobile. Long-term periods of sitting, especially in a forward position, will over-load the spinal discs. Such loading can even affect school children, who sit a great deal and often have symptoms of pain in the lower back, chest and neck. Lack of exercise and poor posture will usually affect the thoracic spine first with stiffness developing by puberty. Mobility is normally less in this area due to the phYSiologically kyphosis structure of vertebrae and due to the stabilizing effect of the rib cage. Therefore, stiffening will tend to affect this area more easily while stiffness in the lumbar spine tends to develop at a later stage. Thoracic stiffness causing upper back pain is especially common during early middle age. It is also the more common cause of chest pain in advanced age compared to heart diseases. Deep breathing is important in back function. During deep inhalation the spine will extend, while during exhalation cervical and lumbar lordosis increase, as does thoracic kyphosis. The movement causing alteration in compression on the spinal discs will improve metabolism by diffusion. This pumping system will be less efficient with poor posture. Stiffness will also limit rib cage mobility, which consequently will restrict deep respiration. Thus, lack of mobility in the spine will decrease general function in the elderly. Breathing is important for muscle function. Deep inhalation activates neck, shoulder and chest muscles and is an effective method of mobilizing the chest area. Forceful exhalation will activate the cervical, chest, abdominal and back muscles. Maximum exhalation will increase forward bending. Breathing exercises with stretching have been used effectively, particularly in yoga, to relax muscles and improve mobility. The onset of disc degeneration in the lumbar spine has been shown to exist even in school children. This is primarily due to innate structural characteristics of the disc tissue. Problems will affect all the joint discs but due to pressure degeneration will be more prominent in the lumbar spine. Unusual and sudden intense loading may cause damage and lead to degeneration in otherwise healthy discs. Nucleus _pulposa is the soft centre of the disc, which is surrounded and encased by dense connective tissue of annulus fibrosus. No nerves or blood

vessels infiltrate the nucleus pulposa. Degeneration causing the breakdown and stretching of the annulus fibrosus can lead to disc rupture, protrusion or prolapse. All these conditions may cause intense neck or back pain, when they appear in the posterior side of the annulus fibrosus, which is well innervated. A strong reflex reaction associated with pain causes the paravertebral muscles to tense up. The quadratus lumborum muscle and the iliopsoas muscle are often involved as well. intensive long-standing muscle contraction decreases circulation in muscles and they become stiff, tender and painful. Stretching and mobilization can relieve back pain caused by tense muscles and disc prolapse will disappear spontaneously in most cases. Herniation of the nucleus pulposa through the outer layer of annulus fibrosus due to degeneration and breakdown is known as disc prolapse and causes intense pain accompanied by protective muscle spasm to prevent movement. Sciatica can be caused by pressure at the root of the sciatic nerve by disc hernia or by chemical irritation by smaller amounts of acidic nucleus pulposa. The pinched nerve will be stretched in the canal between vertebrae or spinal canal, if the straight leg is raised up while the patient is lying supine as in the Lasegue test (Figure 1.28). This will automatically cause protective muscle spasm in the hamstrings, which will prevent further stretching of the nerve root and will noticeably limit hip mobility. Hip flexion becomes difficult when raising the leg while lying or bending forward while standing. Some patients will not experience any back pain with disc prolapse, but only pain symptoms referred to the lower extremity and mobility will be limited. Rarely, there may be hamstring spasm without any pain in the leg. Intense stretching may result in nerve damage in cases of prolapsed disc. Thus, hard resistance ca used by hamstring muscles, which does not give way with CR, testing is a contraindication for any stretching including 55. Back pain often appears before actual disc degeneration can be found with X-ray or magnetic resonance imaging. Disc degeneration may proceed symptomless and thus disc hernia may occur without prior symptoms. In many cases symptoms begin during childhood and it takes often several years before protrusion or rupture

develops. Disc degeneration develops gradually with fluid reduction and the back becomes stiff. In some people back stiffness will be accompanied by pain, especially if immobility develops only in some discs and not evenly throughout the spine. The stiff area in the spine will cause via long moment arm twisting pressure on the first mobile segment and may induce pain and protective muscle spasm. Active stretching, mobilization and manipulation will be considered as forms of treatment. Hypermobility can cause similar symptoms, but does not benefit from stretching or mobilization. Treatment planning will be aided by clinical testing of mobility to determine the cause and best treatment. Postural changes such as straightening of the thoracic spine and exaggerated kyphosis increase stiffness. In scoliosis of the spine mobility will be decreased on the convex scoliosis of the spine mobility will be decreased on the convex side of the curve, while on the concave side mobility will be increased. Straightening of the lumbar spine causes restriction in extension and lateral flexion but in some cases will also limit forward flexion. Excessive lordosis in the lumbar spine increases mobility in every direction. Back mobility has been shown to be better in children who actively move and exercise. Postural examinations of school children should include back mobility evaluation as well as checking for possible scoliosis. Exercises to improve and preserve back mobility could be advised in cases where stiffness is detected. Halbertsma et al (2001) studied the extensibility and stiffness of the hamstrings in patients with nonspecific low back pain. The patient group showed a significant restriction in ROM and extensibility of the hamstrings compared with healthy controls. No Significant difference in hamstring muscle stiffness was found between both groups. Thus, the restricted motion in patients was not caused by increased muscle stiffness, bu t determined by the decreased stretch tolerance associated with back pain. Controlled research of the effects of stretching on chronic back pain is minimal, because treatments usually include other forms of conditiOning as well, making it difficult to isolate results. Elnaggar et al (1991) compared flexion and extension stretching exercises in patients

suffering from chronic back pain. Treatment included repeated dynamic and 55 teclmiques. Symptoms of pain were relieved in both groups to the same extent, but an increase in mobility was recorded only in those using flexion exercises. Khalil et al (1992) conducted research on the effects of 55 techniques on chronic back pain diagnosed as being caused by muscle condition. A control group received physiotherapy, traction of the 1 umbar spine stretching, and strengthening exercises. In addition to that the stretching group received stretches which were systematically given by the two therapists. Local applications of cold were used prior to stretching. 55 techniques were maintained, depending on the individual, from 2 sec to 2 min and repeated three times each treatment day; there was a total of four treatment days in a 2-week period. Stretches were directed to the paraspinal muscles, quadratus lumborum, the tensor fascia latae and the hamstrings. The lower back was stretched into flexion, extension and rotation. Stretching was taken as far as pain tolerance would allow. The rehabilitation programme showed a high rate of success. In the beginning, average back pain was moderate or severe, measured by visual analogue scale (VAS; 0-100). Pain reduced significantly following stretching treatment, as decreased from 63 to 16 on the VAS. In the control group pain decreased only from 71 to 53 on the, which is not clinically significant. Self-assessment: back problems How do kyphosis, lordosis and scoliosis affect thoracic and lumbar spine mobility? In what way will disc and facet joint degeneration affect back mobility? Name the primary muscles commonly affecting