

Back Pain: How to Get Rid of It Forever

Volume 1: The Causes

By John Perrier, B.Phty

Physiotherapist

Published by JP Publishing Australia

www.JPpublishingAUSTRALIA.com

Smashwords edition

Copyright 2015 John Perrier
Professional Reviews for "Back Pain"

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### REVIEW ONE

This book is a comprehensive account of back pain offering a clear insight into this often complex topic. It offers the reader a genuine guide to managing this condition without the spurious "miracle cure". His breezy, conversational style takes the reader through a number of the most important related issues including posture, exercise, diet and stress. He then deftly reviews current treatments and fads, exploding a few myths on the way.

The end result? One of the most informative surveys of back pain to date. This is a must read for anyone who wants to be in control of one of the most out of control topics in current health care.

Graham Sanders B.App.Sc (osteopathy) Grad Dip MedSc

President Australian Osteopathic Association (Qld)

### REVIEW TWO

Laughter is the best medicine. In this book there's a regular dose of humour that will not only maintain your interest, but will undoubtedly help to lighten your back pain.

This book contains quality information that is thoroughly explained, including a unique self-assessment quiz that assists readers to evaluate their own spinal pain. The author, using current research to support his methods, then guides the reader on how to successfully resolve their own problems in a step-by-step, logical manner. An excellent read.

John Miller, B. Phty, MAPA

Physiotherapist with special interest in back pain, Secretary of the PhysioWorks group.

### REVIEW THREE

John Perrier has written the best self-help back book I have ever read. It's based on a mix of John's own methods for managing and preventing your own pain, and the most recent scientific data. I recommend it without reservation.

Keith Charlton, Dr of Chiropractic, MACA

Former Governor of Australian Spinal Research Foundation, President Australian Chiropractors Association (Qld) and Honorary Fellow of the Division of Science & Technology at Griffith University

### REVIEW FOUR

Many of my patients are looking for the answer to managing chronic back pain. This book talks about self-treatment in a plain-English style, encouraging the reader to learn more about the way their body needs help to work effectively. Popular myths are dispelled and replaced with a treatment approach based on well-explained research and the knowledge of an experienced practitioner.

In short, this text adopts a sensible, realistic and 'do-able' approach to self-management of chronic back pain.

Dr Andrew Grimes, MBBS, FRACGP

Cleveland Family Practice Medical Centre, Brisbane.

##  About this book

The title says it all: this book will help you permanently banish your back pain. In two volumes, it shows you how to feel better.

_Volume 1: The Causes_ , makes it easy for you to understand your back pain. Using simple, clear language it explains the structure of your spine, and demystifies many common pain-provoking conditions.

_Volume 2: The Cures,_ offers a unique quiz that will help you to classify your injury into one of four types. In this way you will learn how to cure _your_ pain, not someone else's. Then the advice flows thick and fast. You will learn clever techniques that will help you to use your spine more efficiently, and discover how to think, eat, relax, and sleep away your pain. You'll also find useful information on exercises, x-rays, medication and muscles, plus some tips on how to choose a spinal health practitioner. Of course, all of the advice will be tailored to _your_ specific problem.

Because the cure uses well-proven techniques, your relief won't just last a few days or weeks. You will feel better _forever_.

##  Publication information

Licensing details

This ebook is licensed for your personal enjoyment only. You may not re-sell it. Please don't give it away to your friends – that is simply helping them to steal. If you would like to share this book with another person (which, by the way, I strongly encourage) then please ask them to purchase/download their own copy, even if it was originally free.

In short, thank you for respecting my hard work in bringing this book to you!

###

### Copyright notice

This book is copyright. Apart from any fair dealing for the purposes of study, research, criticism, review, or as otherwise permitted under the Copyright Act, no part may be reproduced by any process without written permission. Inquiries should be made to the publisher.

© John Perrier 2015

###

### Catalogue Information

Perrier, John, 1967– .

Back Pain: How to Get Rid of It Forever. Volume One: The Causes

ISBN 978-0-9875694-1-7.

1. Backache – Popular works. 2. Backache – Treatment.
About the Author

John Perrier (b. 1967) graduated from the University of Queensland (Australia) with a Bachelor of Physiotherapy degree in 1989. After a couple of years spent working and travelling, he started his own treatment clinic, and steadily expanded it to include three practices, as well as consulting to hospitals, local industries and elite sports teams. He is the founding chairman of the PhysioWorks group in Australia, and has had original research published in a peer reviewed journal.

## Perrier developed a special interest in treating back pain very early in his career. So far he has treated about 35 000 cases of lower back pain, and learned something from every one of them!

Perrier has written four other books across a variety of genres (more information is available at the end of the book) and enjoys the challenge of communicating ideas simply and with humour.

To see other media associated with 'Back Pain: How to get rid of it Forever', including Perrier's television and radio appearances, please go to www.JPpublishingAUSTRALIA.com, and follow the links under _Back Pain_.

##  Contents

Title page

Professional Reviews for 'Back Pain'

About this book

Publication information

About the author

Acknowledgements

Volume 1: The Causes: An introduction to back pain

Chapter 1: Getting to know your back

Let's get started!

Chapter 2: The Structure and Function of your Spine

Why a Mutant Fish is Responsible for Your Sore Back

\+ The Evolution of your Spine

\+ The Design of the Spine

Chapter 3: What goes Wrong?

How to reduce 129 million problems to just three

\+ Trauma

\+ Wear-and-tear

\+ Other causes of lower back pain

Chapter 4: Intervertebral Disc Injuries

Middle-aged mayhem

\+ Disc bulging due to weakness

\+ A prolapsed disc

\+ Spondylosis

Chapter 5: Facet and Sacro-iliac Joint Injuries

Sprains, strains and rusty bones

\+ Ligament sprains

\+ Coccydynia

\+ Arthritis

Chapter 6: Injuries to the Vertebrae

My bones are broken?

\+ Stress fractures (Spondylolisis)

\+ Displaced vertebra (Spondylolisthesis)

\+ Crush Fractures

Chapter 7: Muscle Injuries

No such thing as a torn back muscle?

\+ Bruising

\+ Spasm

\+ Post-exercise soreness

\+ Trigger Points

Chapter 8: Referred pain

Is your back problem getting on your nerves?

\+ Normal Nerves

\+ Compressed Nerves

Chapter 9: Consequences of nerve compression

Pain, pain, pain and more pain—oh, and some weakness and stiffness as well

\+ Pain

\+ Weakness

\+ Nerve immobility

\+ Summary of nerve-related injuries

Epilogue to Volume One

More great books from JP Publishing Australia

\+ Campervan Kama Sutra

\+ A Few Quiet Beers with God

\+ The Wondrous Adventures of Captain Rum

Connect and Contact

**An abbreviated Index to** _Back Pain: How to get rid of it Forever, Volume Two: The Cures_ _._
Chapter 10: The real cause of lower back pain

Chapter 11: What's your problem?

Chapter 12: Muscle imbalances

Chapter 13: Designing a personalised exercise program

Chapter 14: Exercises to correct muscle imbalances, joint stiffness and neural tension

Chapter 15: Safer sitting

Chapter 16: How to lift and bend more efficiently

Chapter 17: Better ways to walk and stand

Chapter 18: Simple tips for lying and sleeping

Chapter 19: Easing activities of daily living

Chapter 20: The effects of stress on your spine

Chapter 21: Your physical tolerance to stress

Chapter 22: How to decrease stress

Chapter 23: Attitudes, the placebo effect, and the power of the mind

Chapter 24: The effects of drugs

Chapter 25: Diet, Nutritional Supplements and Natural remedies

Chapter 26: Fitness and exercise

Chapter 27: X-rays and scans

Chapter 28: Pregnant women and children

Chapter 29: A few other things that had nowhere else to go

Chapter 30: Heat or Ice?

Chapter 31: Myth busting

Chapter 32: What to do if you are in acute, severe pain

Chapter 33: Choosing a spinal health practitioner

Chapter 34: Which spinal health practitioner is best for you?

Chapter 35: Putting it all together

##  Acknowledgements

I've occasionally glanced at the 'acknowledgements' at the start of other books. They always commence with well-used phrases such as: 'This book would not have been possible without the generous and dedicated support of many people . . . etc.' Usually, I simply skim over this phrase, largely ignoring it as a hackneyed cliché. Well, guess what? It's true!

In my case, this book would not have been possible without the generous and dedicated support of many people. Most of them are busy medical professionals, and all gave freely and generously of their time. To each of these people, I offer my sincere gratitude.

First, to my physiotherapy colleagues, Debbie Creamer, John Miller, Jenny Lawson and Andrew Waldie, for telling me how awful my first drafts were. Thank you very much to spinal surgeon Dr Bill Ryan, General Practitioners Dr David Speed and Dr Andrew Grimes, chiropractor Dr Keith Charlton, and osteopath Mr Graham Sanders, for your technical reviews and comments on the entire text. You are all very clever people.

I would also like to thank Dr Fred Schubert for his help with the radiology section, dietician Lisa O'Brien for reviewing the diet and nutrition segment, and Ian McKenzie for helping with the relaxation and positive thinking chapters. My gratitude also goes to pharmacist Scherelle Waldie for her considerable help with the drugs chapter. Another pharmacist also reviewed this section for me, but she did not want to be identified. Her name, were it a cryptic crossword clue, would read something like 'gets a herb for Mrs Free Horny Ace'. So thanks for your help. Thanks also to Chris Fechner for helping me with my ever-troublesome computer, and to my colleague and co-worker Steven Schamburg for his help with the back pain classification quiz.

My gratitude also goes out to the secretaries, presidents and committee members of various professional associations, including the Australian Chiropractic Association, the Australian Osteopathic Association, the Australian Natural Medicine Association, the Australian Acupuncture and Chinese Medicine Association, and the Australian Natural Therapists Association, for the information on your various professions. Thanks also to the Australian College of Natural Medicine, the Australian Feldenkrais Guild, the Queensland School of Reflexology and the Arthritis Foundation of Queensland for the advice and material on your specialties. Thanks also to Wendy Lockett for your help on reflexology, and for the foot massage.

I also acknowledge the work of Bert Weir, whose lectures at the Relaxation Centre of Brisbane have already helped thousands of people. Thanks also to Cathy Nash, Clare Stevens, Johnny Godwin and Andrew King for their input. Of course, many thanks to my supermodels Greg Everding and Debbie Creamer, and to Henri Van Nordenberg for his advice on the photographs.

I am also indebted to those patients who completed a back pain questionnaire to help me with my research. This book would not have been possible without your co-operation. I hope your backs are still feeling better, by the way.

I am most grateful to Bert, Heather and the rest of the team at my original publishers, Hale & Iremonger. I hope your new projects are humming along as smoothly as your days at H&I.

See what I mean about a lot of dedicated people. By the way, if you're reading this and thinking 'Gee, I gave John a lot of help with his manuscript, and he hasn't even thanked me,' then I apologise profusely. I'm terrified that I've left someone out, and, if that includes you, then I thank you from the bottom of my heart.

Last but not least, thank you to my beautiful wife Kath, for putting up with me, and for putting up with the absence of me, while I wrote this book.

Dedicated to my Mum, and my late Dad, who was forever suffering with back pain.

#  Volume 1: The Causes

# An introduction to back pain

## Chapter 1: Getting to know your back

###  _Let's get started!_

The title of this section, 'An introduction to back pain', is a bit misleading. I'm sure that you already know back pain very well. Whether your particular version is aching, burning, jabbing or gnawing, I bet that you need no further introduction. I hope that by the end of this book and its companion volume, you'll have the knowledge and techniques to say goodbye to your back pain forever.

About five billion people around the planet are currently suffering, or will soon suffer from, spinal pain of some sort. No, I didn't take a survey. Medical statistics tell us that about 80% of people will have back problems at some stage during their lives, so my estimate is probably pretty accurate. Five billion cases of back problems! That's a lot of pain. Yet I'm sure that, for you, one case stands out above the rest: Yours.

This book is all about your back pain. And, of course, what you can do to get rid of it.

Back pain is not only very common, it is also very likely to recur. Four out of every five back pain sufferers will have more than one attack. Many of these people develop chronic pain that persists for months, years or even decades. This book is dedicated to preventing these all-too-common repeat, or chronic, problems.

Of course if you've just suffered from your first case of this dreaded affliction, then the techniques and tips that follow will help ensure that it is your last.

As you'll soon come to appreciate, back pain is a very individual problem. Techniques that help one person's pain can cripple someone else. For example, consider these two vastly different cases:

+ An eighty-year-old retiree, whose back stiffens and aches after he has been sitting in his easy chair for an hour, and

+ A fifteen-year-old gymnast, whose lower spine catches with a sharp pain each time she does a back flip.

These two types of problems are totally different, and so require separate solutions. Likewise, I'm sure your spine has its own unique characteristics and problems. As we go we'll explore various types of spinal problems, and then provide specific, tailored advice for your particular case. In this way, you will learn solutions that are likely to help your problem, not someone else's.

Like most worthwhile pursuits, the solutions may require some hard work. You may have to make changes to yourself, to your habits, your lifestyle, and even to your way of thinking, if you hope to permanently alleviate your back problems. This book will show you how, and why, you need to take these important steps.

In doing this, we will first take a light-hearted look at the evolution of the spine. You will learn how this remarkable piece of engineering progressed from a stiff band of cartilage to become its current amazing and complex series of interlocking bits. Then, we'll take a closer look at these interlocking bits to discover how and why the spine works. Finally, to complete Volume One, you will learn what can go wrong with your spine, including the bones, joints, discs, ligaments and nerves.

After that you'll need to go to Volume Two – the Cures. In this volume we tackle the big issues, including a self-assessment section where you'll analyse the nature and behaviour of your problem. You'll complete a very important quiz that will classify your spinal problem into one of four types. (You can also perform this analysis via a downloadable link.) The results of this quiz, along with your gradually accruing knowledge, will enable you to identify the advice that most relates to your specific problem.

From this point onwards the enlightenment flows thick and fast. You will learn how to simplify common tasks such as sitting, lifting and standing. Through this discussion we will interweave advice on aspects such as your chair, work station and bed, and offer tips to simplify your household and work tasks. Importantly, you will learn vital exercises that will help to cure the underlying cause of your problem.

You will also discover many other ways of helping your spine through fitness programs, diet, nutritional supplements and medication. We'll have a thorough look at relaxation and positive thinking, and the role that your mind plays in the rehabilitation process. Not only that, but we'll be debunking a few myths and unproven treatments along the way.

Towards the end, we'll look at how to choose a good spinal health practitioner, and examine the various types of therapies and treatment options that are available to help you.

Finally, the last chapter will show you how to systematically design your own rehabilitation program. Once you have completed this chapter, you will have a blueprint for a program that will help you to get rid of your back pain forever.

Let's get started!

##  Chapter 2: The Structure and Function of your Spine

### Why a Mutant Fish is Responsible for Your Sore Back

If you asked an inventor or an overpaid corporate engineer to design a gadget, the first thing that they would want to know is what it was supposed to do. No sensible person would design an object and then assign it a use when they had finished. Usually, the design of something depends upon its purpose. Function dictates structure.

Your spine is no different. Its myriad of strange shapes and complex joints serve very worthwhile purposes. Those funny little pointy bits on the bones did not appear by accident. If you understand the function of your back, and how those demands evolved, then you will find it far easier to appreciate its bizarre structure. Later, armed with this knowledge, you can confidently tackle tasks such as diagnosing and preventing your own back pain.

### The Evolution of your Spine

Mother Nature designed your spinal column over a very long period. Helped by her design team of natural selection and evolution, she gradually fashioned the extremely complex systems that form the human spine.

The process began about half a billion years ago when an otherwise inconspicuous ocean-dwelling animal called an Elasmobranch developed a spine. The Elasmobranch's spine was a flimsy affair: its chief function was to provide protection for the bundle of nerve fibres that ran down the creature's back. Despite this inauspicious beginning, the vertebral column had arrived.

Over the next lazy 100 million years or so, other sea life such as primitive fish slowly evolved spines. These spines were also very simple, and made from soft cartilage rather than bone. They gradually assumed another job besides protecting the nerves: to provide an attachment for the fish's muscles. This extra control allowed them to swim, and thus survive, more efficiently.

Then, about 400 million years ago, the fish did something that had a huge effect on our spinal development: they migrated to land. With this audacious move came a new problem for the spine. Gravity.

Helped along by the very small changes that are evident from one generation to the next, these early amphibians gradually developed newer, different models of the spine. The quality control manager, natural selection, tested each new design. Those animals with more efficient spines had a better survival rate, meaning that their descendants, the reptiles, inherited better backs.

By the time mammals arrived about 250 million years ago, the vertebral column had developed many desirable characteristics:
+ The individual building blocks of the spine were now constructed from dense bone rather than cartilage. This change allowed them to bear more weight.

+ The vertebrae—the back bones—developed joint structures that allowed extra movement.

+ Shock-absorbing mechanisms evolved that helped to protect the bones from fracturing in the rough-and-tumble of prehistoric Earth.

+ Strange lumps and bumps of bone developed on the vertebrae. These protuberances provided leverage for muscle attachments, allowing more precise movement control.

For a time, everything went smoothly in Mother Nature's spinal design department. She had an efficient, working model that allowed good movement, offered a firm attachment point for both muscles and ribs, while offering vital protection to essential nerve structures.

Then about fifteen million years ago, probably on an otherwise ordinary Tuesday or Wednesday afternoon, all that contentment dramatically changed. Something happened that would alter the requirements of the spine, and therefore its structure, forever: an apelike creature began to walk on two legs.

Why did the ape do this? Well, nobody knows for sure. However, scientists and anthropologists suspect that the motivation was so that the creature could use its front legs—its arms—for tasks such as using crude tools, or brandishing weapons for self-defence. The two-legged stance also liberated the front legs for the useful purpose of carrying objects, like food. Or beer cans.

Mother Nature and her design team now had to enable the spine to cope with a new functional requirement: to support the trunk in the upright position. Suddenly, the architecture of the lower back needed a drastic overhaul. Undoubtedly, the first versions were poor. Any decent spinal health practitioner would have made a fortune had they been around during these early reformative millennia. However, as the centuries ticked by, evolution again provided gradual improvements. The pelvis and hips gradually changed their alignment so that the legs were roughly in line with the trunk, rather than jutting out at right angles like a quadruped's limbs. The abdominal muscles also changed their function so that they supported the spine in an upright position, rather than simply being a sling for the stomach and intestines.

As we developed, tree climbing became an occasional diversion rather than a semi-permanent home. Our tails, which were no longer necessary, steadily disappeared ... which I, for one, think is a bit of a shame. Imagine how much fun you could have at a party with a fully functioning tail.

Recently, only a mere two or three million years ago, we human beings emerged from the developing gene pool. We now walked upright most of the time. In response, the spine made one further adaptation: it developed some inward and outward curves. Besides providing some extra leverage for the postural muscles, the curves had a springlike effect that helped the spine to absorb shock.

Finally, after a 500 million year journey that started with a mutant fish, the spine arrived at the current model.

Despite the miracle of design, I award Mother Nature only nine out of ten for her efforts in spinal architecture. Why the deducted mark?

The lower back is probably the weakest mechanical link in the entire human body. It is responsible for more musculoskeletal pain than any other area. Compared with other masterpieces like the eye, the brain and the hand, the lower back looks decidedly amateurish. Paradoxically, the probable reason for this weakness also lies in the mechanism of evolution.

In our earliest caveman days, health problems of all kinds beset the average human being. Even a simple cut or abrasion was often fatal, while the most common form of death was infection from tooth decay! Because of these appalling health problems, most human beings died at a very young age, usually less than thirty. Of course, most reproduction and parenting had to be completed by the early twenties to squeeze into this limited lifespan. Due to the early parenting age, the natural selection process had no chance to attack the residual problems in the lower part of the spine. Most people had already produced their offspring and/or were dead before they had even begun to develop a bad back, which, as we will see later, usually occurs first in early middle age.

So we passed this weak genetic link from one generation to the next, while it patiently waited to make its presence felt when the human lifespan elongated. Now, as the average length of life approaches eighty years, we are, as a race, suffering from far more back pain than our early ancestors could have imagined.

Yet for all its problems, our spine is an amazing and complex piece of machinery. Try to envisage any other design that not only protects the nerves that carry signals from the brain to the limbs, but provides efficient attachment for both ribs and muscles. Of course, this design would also have to allow plenty of movement without being unstable or floppy, protect itself with shock absorption, and stay upright while being supported on only two legs.

As you can see, we place many demands on our spines. Now, we will look at the design that Mother Nature developed to cope with all these requirements.

###

### The Design of the Spine

Let's now take a closer look at all the knobbly bits and strange twists in your spine. First, we will consider the spine as a whole. Then, we'll examine it piece by piece to see how it achieves its remarkable diversity of roles.

Most of the lumps and bumps have long scientific names, which I'll try to avoid where possible. There's nothing worse than technical jargon to ruin a good story, is there? However, in some circumstances, the anatomical name is actually easier. For example, writing the word 'ligament' is far easier than 'the tough strands of fibre that hold two bones together'. Likewise, I'm sure you'd find it irritating if I repeatedly wrote 'the strong elastic fibre that joins a muscle to a bone' instead of simply using the word 'tendon'. So I'll use a few anatomical terms, but there won't be many, I promise.

Your whole spine is known as either your vertebral or spinal column. It consists of twenty-six bones, which are individually known as vertebra, stacked on top of each other. Two or more of these bones are known by the plural term vertebrae.

The spine has four main areas, which have common and scientific names. The upper part, the neck, consists of seven vertebrae and is called the cervical spine. The next part, the thoracic spine, is distinguished by a pair of ribs that attaches to each of the twelve vertebra. While this book is primarily directed at lower back pain, most of the principles and techniques can also be applied to problems that arise in the thoracic spine.

Figure 1: A side view of the whole spine, showing the cervical, thoracic and lumbar areas, as well as the sacrum and the coccyx.

Below the thorax is our main area of interest, the lower back, or lumbar spine. This area has five vertebrae, whose main task is to provide movement. If you have ever experienced lower back pain, I'll bet you sometimes wished that this part didn't exist.

The lumbar spine sits atop a large triangular bone called the sacrum, which connects the lower back to the pelvis. The sacrum is an interesting bone, consisting of five vertebrae that fused during the evolutionary process.

The point at which the sacrum meets the pelvis is known as the sacro-iliac joint (say-cro-ill-ee-ack). Known as the SIJ to its mates, this joint does not bend or move very far, as it is fixed in place by many strong ligaments. However, it still contributes to your overall spinal movement by a sliding and gliding motion of the adjacent joint surfaces. These small positional changes at the sacro-iliac joint help to absorb shock, and allow the pelvis to adjust when the lower back moves. Like all joints in the lower back, the sacro-iliac joint can be injured and can cause pain.

If you have been counting, you will notice that we have now covered twenty-five vertebrae, not twenty-six. The missing bone is the coccyx (cox-six) which is a tiny triangular bone that attaches to the bottom of your sacrum. This bone is the remnants of what was once your tail, tens of millions of years ago. The coccyx now sadly lacks any major functional use, and is about as useful to you as is your appendix.

Does this mean that the coccyx never hurts? Unfortunately, no. The coccyx still finds a way to be involved in a few different pain syndromes, which we will investigate later.

Some textbooks report that the spine has thirty-three bones, not twenty-six as stated above. This difference arises because some health practitioners count the vertebrae that fused to form the sacrum and coccyx as individual bones. Personally, I think that this counting method is a bit outdated. The vertebrae melded together in the evolutionary process a couple of hundred million years ago!

A simple code is used to name each individual vertebra. A letter represents the area—either a 'C', a 'T' an 'L' or an 'S'. You can probably guess that these letters represent the four main areas of the spine: Cervical, Thoracic, Lumbar and Sacral. The coccyx, I guess because the cervical spine already took the letter 'C', does not score an abbreviated nickname. The poor coccyx, doomed not only to a useless existence, but to a complicated, unabbreviated name as well.

A number is then added that signifies to which bone you are referring. For example, the first bone in the neck is known as C1, the ninth vertebra in the thorax is T9, while the last bone in the lumbar spine is called L5. You should also be aware that the Bananas in Pyjamas are known as B1 and B2, and that little robot from Star Wars was called R2D2, although I admit this has nothing to do with back pain whatsoever.

Viewed from the side, your spine resembles an elongated 'S' shape. Some areas curve inwards in a concave fashion, while some curve outwards. In what was probably a move designed simply to confuse ordinary people like you and me, these curves have complicated names. An inward curve in your spine is called a lordosis, while a convex curve is known as a kyphosis.

So, in a normal standing posture, your lower back and neck have a lordosis, while your thoracic spine has a kyphosis. Later, we will see how maintaining the balance of these curves is vital to protecting your spine.

Figure 2: The big names for the curves of your spine.

The building blocks of your spine, the vertebrae, have fascinating shapes. The main part of a vertebra, the body, is an oval-shaped cylinder of bone. Actually, it's not really oval shaped—that's just how anatomy textbooks describe it. For me, the vertebral body looks more like a squashed baked bean.

Projecting off this squashed-baked-bean-shaped body is an arch of bone. When all your vertebrae are stacked on top of each other, this arch forms a tunnel through which your spinal cord traverses from your brain to your limbs. Thus, a very hard, stable tunnel of bone protects these vital nerve fibres.

The bony arch has bumps of bone that protrude from it at various angles. If you look at a vertebra from the top, you will see two arms of bone that extend sideways, and one, the spinous process, that juts straight backwards. You can feel the spinous process under your skin. These three arms act as anchorage points for muscles and ligaments.

Figure 3: A standard lumbar vertebra, when viewed from the top. See what I mean about the squashed baked bean? Note also the pointy bits – the processes - and the hole that forms a tunnel for the spinal cord.

The leverage provided by these three arms makes the spine far more efficient. If your vertebrae did not have these bumps, then the ligaments and muscles would have to be far stronger and thicker, meaning that your spine would lose much of its flexibility. It's a great idea when you think about it—using little pointy bits of bone to increase the strength of your spine, without sacrificing its flexibility. A big tick to whoever thought of that one.

Each vertebral arch has four other protrusions on its arch called facets. One pair of these facets point up, the other pair points down. When the bones are arranged on top of each other as in a normal spine, each pair of facets connects snugly with the corresponding pair of facets from the next vertebra. Held together by the obligatory ligaments, these joints are called—wait for it—the zygapophyseal joints.

As this word has far too many syllables to be used without sounding pretentious, we'll just call them the facet joints. These small joints help to guide and control the movement of your spine. Without them, your torso would be very unstable and floppy. Problems that can affect other joints—such as ligament sprains, swelling, or arthritis—can also affect your facet joints.

Figure 4: Two vertebrae mating ... er, sorry ... joined together. Note how the facets fit snugly upon each other, forming a facet joint. I've also pictures a few ligaments, although normally there's a lot more. Originally I tried to include them all, but the picture looked like a ball of steel wool.

Each vertebra has one other very important connection with its neighbouring bones: a tough, sponge-like structure known as an intervertebral disc, or just plain old 'disc' for short. The discs help to absorb pressure and cushion shock, while also allowing some movement between the bones. To help them achieve these aims, they have a very clever structure, comprising a series of leathery rings around a soft centre.

The soft centre, or nucleus, of the disc gradually dries and hardens as you age. When we were young your disc's nucleus was very liquid. 'Vanilla pudding' and 'jelly' are two terms often used to describe its consistency, although to me these sound more like my favourite desserts.

By the time you were twenty, the nucleus has already started to dehydrate, and by your late forties it was/will be like thick toothpaste. When we are in our sixties, the once nubile nucleus is said to resemble, and I quote, 'crab meat'. Those anatomy experts really have a thing about food, don't they?

To hold the nucleus in place your discs use concentric rings of tough fibre known as the annulus. These sinewy layers are aligned with a criss-crossed pattern, with one layer slanting diagonally down from left to right, with the next layer tilting in the other direction. This arrangement is sensible, as it ensures that your disc can withstand twisting forces in both directions. If one layer of fibre loosens, the fibres on the opposite slant become more taut. In this way the annulus retains a firm hold over the nucleus, no matter which way you turn.

Figure 5: A simplified front view of a two vertebrae, showing the criss-crossed orientation of the fibres of the annulus.

Finally, many nerves exit your spine to travel to the limbs and trunk, while groups of muscles support and move your spine. As we will be discussing muscles and nerves later in the book, I'm going to ignore them for now. You've already had enough big words for one chapter.

In summary, evolution has designed for you a system of twenty-six strangely shaped vertebrae that form your spinal column. By using the bony bumps to increase its efficiency, and facet joints and discs to guide the movement, your spine can bend in almost any direction without losing stability. An ingenious tunnel of bone protects your spinal cord, just as it did with those early elasmobranches. Somehow, the whole thing manages to stay upright for two-legged gait.

The spine has come a long way in just 500 million years, hasn't it?

##  Chapter 3: What goes wrong?

### How to reduce 129 million problems to just three

Back pain is rarely simple. I'd be out of a job if it was! The spine has potential for an almost infinite variety of problems, which can arise from any of its anatomical structures; pain can emanate from not only the discs, joints and ligaments, but the muscles and nerves as well.

To cloud any attempt at an accurate diagnosis even further, the problem may not be isolated to just one type of structure, but spread across a range of interrelated anatomical bits and pieces. For example, an injured disc can push on a nerve, which then causes a muscle to spasm in another part of the back. Not only that, but injuries can affect each of these structures in many different ways. Consider a facet joint, which can sprain, degenerate, or sometimes even fracture.

To illustrate how difficult arriving at a perfect diagnosis can be, pretend for a moment that the lumbar spine consists only of the bones and joints, and ignore the muscles, nerves, tendons and everything else. Your lower back has five discs, ten facet joints and two sacroiliac joints, making a combined total of 17 joints. Also, pretend that you can only injure them in two different ways: stiff or unstable, for example. Some 'simple' mathematics will tell you that the total number of potential problems from these 17 joints is a staggering 129,140,163!

If you are like me, then you consider the term 'simple mathematics' to be an oxymoron. In truth, my wife is a maths teacher, and she figured this out for me. Nevertheless, some readers may be wondering how I derived the seemingly unbelievable number of 129 million different types of back pain from such a simplified situation. This figure represents 317 , i.e. three multiplied by itself 17 times. This calculation assumes that any combination of joints, from a single joint through to all seventeen joints simultaneously, may be causing the pain. I admit this is highly theoretical argument, but at least it illustrates how difficult it can be to precisely diagnose back pain.

Does this huge number of potential problems mean that no one will ever properly diagnose your back injury? Should you simply concede that your back pain is too complex, and that it will never be cured? Perhaps you should just quit your job, ignore the housework, let the garden overgrow, and retire to a deck chair to sip on a cool drink for the rest of your days. Well, as tempting as that may sound . . . no.

Your spine has weak links that are often the first places to break down. So while your spine may have problem number 129,140,162, chances are that you are suffering from a well-defined condition. Moreover, many spinal health practitioners are adept at diagnosing such problems, and sometimes even know how to fix them!

Let's now look at the three basic categories of lower back problems. After that, we'll look at about a dozen common conditions in detail. There are three broad groups of spinal problems:

1. Trauma

2. Wear-and-tear

and, that wonderful group that covers everything else that is too complicated to neatly fit into any other category:

3. Other.

Let's now look briefly at the characteristics of these three main groups.

###

### Trauma

Trauma is defined by my Dictionary as

: trauma /'tr$mE/, n., pl. -mata

/ -mEtE/,-mas. 1. Pathol. a . . .

Oh, who cares what the dictionary says. I could never understand what all those little upside-down letters mean anyway. Put simply, trauma is an injury sustained by a violent force.

By violent, I mean violent. A sneeze does not count as violent, nor does picking up a box. Moreover, I don't consider that sexual activity is violent, not even very acrobatic sex . . . none that I have ever been involved in, at any rate.

Usually a traumatic injury will involve high speed, such as a car crash or sporting accident, or a great force, such as a collapsing wall. In other words, traumatic back pain is readily distinguishable by its history. Humpty Dumpty was a classic example.

The symptoms of physical trauma are very recognisable: bruising, swelling, and severe and/or unusual pain. The location and extent of the injury will not follow any typical pattern, as these signs depend on other factors, such as the shape of the bumper bar that hit you.

If you are unlucky enough to suffer from a traumatic injury to your vertebral column, then you will probably require specialist help. By all means try the principles outlined in this book, but be aware that your injury might respond differently to 'normal' back pain.

###

### Wear-and-tear

The vast majority of people who have back problems, which probably includes you, suffer from wear-and-tear of some description. The main characteristic of these injuries is that the pain resulted from a nonviolent incident. It includes those people who first felt their symptoms after undertaking an activity that was unusual, or after attempting a job that was heavy, prolonged or repetitive. This group also includes people whose pain simply started for no apparent reason.

Some typical histories associated with wear-and-tear injuries include:

+ I was just trying to move the piano a few metres...

+ It was match point, and as I lunged for (what would have been) the winning volley I felt a twinge...

+ I must have slept on it strangely...

+ We drove back from my mother-in-law's place in the country last weekend...

\+ My boss has been really annoying me at work, so I'm feeling stressed...

+ I just bent over to tie my shoelaces and felt something go....

As you can see from this list, our natural human reaction is to look for a cause—someone or something to blame—for our back pain. Most people implicate the activity that immediately preceded their pain, like tying their shoelaces, for example. They heap all the blame for their lower back problem upon this single unfortunate incident, and respond by buying a pair of Velcro sandals, vowing never to tie another set of shoelaces again.

But wait! Before you spend your hard-earned dollars on footwear that will cast your wardrobe back to the seventies, think about the situation more carefully. You've tied your shoelaces thousands of times before without any problems. Why did the pain start this time?

The reason that your pain began suddenly is that your spine had already developed considerable wear-and-tear. You may have felt a few warning signs, such as a few twinges here and there, a bit of stiffness in the mornings, perhaps some backache 'like everybody gets'. Or you may not have felt any warning signs at all. Either way, your back would not have broken down in such a simple situation had it been strong and healthy. Almost certainly, your spine had already degenerated, and this incident was simply letting you know that your spine had reached its breaking point.

The shoelace-tying incident was, to use a badly chosen metaphor, the straw that broke the camel's back. A spine that is one hundred per cent healthy can withstand amazingly high pressure. Consider the gruelling force that some athletes exert on their spines—a rugby prop forward, for example. Or think of the punishment absorbed by the lower back of a builder's labourer who lifts a hundred railway sleepers before he's even downed his first pie for the day.

The reason that your back pain arrived so suddenly after tying your shoelaces, with so little provocation, is best understood if you think of your spine as being similar to an old-fashioned light bulb. Every night you walk into, say, your bedroom, and switch on the light. You repeat this process hundreds of times, night after night after night. Then one evening, without warning or fanfare, the light flickers, emits a mild hiss, and dies. Usually, of course, this happens when your wife is already in the car, honking the horn with increasing regularity, while you search frantically in the dark for your bow tie . . . but I digress.

What happened to the light bulb? Simply, the wear-and-tear in the filament had progressed to the point where it could no longer manage. So it collapsed. No sensible person would assume that the light bulb expired because of the way that they flicked the switch. Your lower back is the same. The daily grind to which you subject your spine gradually wears it away. Slowly but steadily, the years take their toll, sometimes without any warning signs at all. Then one day, for no apparent reason, your spine 'goes'. Just like a light bulb.

If a qualified light technician had carefully examined the light bulb's filament a week or so before it blew, he or she could probably have told you that it was deteriorating. In the same way, if a competent spinal health practitioner examined your back just before the onset of your pain then the damage would already have been evident. However, no one ever checks their light bulbs in advance. Unfortunately, most people take the same attitude with their spines. We prefer, for some reason, to find out the hard way.

The fancy term for this process of gradual deterioration is repetitive microtrauma. Understanding this concept is important, as it underlies almost every non-traumatic spinal injury. Microtrauma refers to tiny injuries; injuries that are so small that you cannot feel them. Yet when the damage accumulates over many years it can reach a devastating level.

To explain further how accumulated microtrauma relates to lower back pain, we should also consider how the body attempts to heal these insidious injuries. When performing your usual daily activities, the normal stresses and strains cause microscopic damage that is quite normal, and is usually so insignificant that you don't realise that it has occurred. Usually the body heals these injuries quickly, so that the tissues have repaired themselves by the next day.

However if the activity that causes the microtrauma is too damaging, or is repeated too frequently, then your body cannot fully repair the microscopic tears in time. When you again stress the now slightly injured tissues, further microtrauma is the result. As this cycle continues, the inflammation and scar tissue steadily accumulate. Of course, these changes further weaken your spine, rendering it even more vulnerable to injury. A vicious cycle develops. After days, weeks or even years, you suddenly notice pain or stiffness. An injury!

Figure 6: The vicious cycle of microtrauma, from which can sometimes be very difficult to escape. Hence the little sad emoticon face.

Often during my years of clinical practice I have explained to patients that their sudden or recent back pain was due to the gradual degeneration associated with repetitive microtrauma. Most patients naturally then ask what caused the degeneration. This very simple question has a very complex answer!

My usual time-limited response was to cite a few straightforward examples such as poor posture, stress and bad habits, while muttering that someday I'd write a book to explain it properly. Well, here it is! Most of the chapters in these two volumes are dedicated to unravelling the complex answer to the question of why our backs degenerate with such alarming frequency.

Suffice to say at this stage that most back pain, probably including yours, is due to repetitive microtrauma.

###

### Other causes of lower back pain

This broad band of spinal problems covers all those pesky conditions that won't fit neatly into one of the previous categories. They range from common conditions such as an achey 'flu to the downright serious, such as spinal cancer. Luckily most of the nasty conditions are rare. I've listed some other causes of back pain here, not to alarm you, but so that you are aware that they exist:

+ Cancer and other tumours

+ Viral conditions, such as the flu, Ross River Fever, etc.

+ Shingles

+ Kidney problems

+ Inflammatory conditions, such as Ankylosing Spondylitis

+ Stomach ulcers

+ Tuberculosis

+ Meningitis

+ Infected bones

+ Lung problems

+ Gall bladder problems

+ An aortic aneurism (a weakened blood vessel in your tummy).

How do you know if you have one of these conditions? Sometimes you don't. But there are usually warning signs that may suggest that your problem is serious. Spinal health practitioners call these signs 'red flags'. Please read the following list carefully. If you have any of these warning signs then don't be brave or overly fearful: simply make an appointment with your doctor.

+ Constant pain that never varies in intensity.

+ Pins and needles or numbness that does not vary in intensity.

+ Pins and needles in both feet or hands that are in a 'sock' or 'glove' distribution.

+ Back pain that began with another illness.

+ Recent unexplained weight loss.

+ Problems elsewhere, such as unexplained vomiting, fever or shortness of breath.

+ Severe headaches and neck stiffness that are associated with your back pain.

+ Family or personal history of cancer or other serious pathology.

+ Persistent morning pain and stiffness that takes more than two hours to warm up.

+ Unusual skin rashes that occur with your spinal pain.

+ Weakness or severe clumsiness in the legs.

+ Pins and needles or numbness in the genital region, particularly if it is combined with incontinence or bowel disturbances.

+ Pain that is worse with rest, particularly persistent night pain.

+ Back pain that began following a urinary tract infection.

+ Night sweats.

Do you have any of these signs? If so, put down whatever device you are reading this book on and make an appointment with your doctor. Go on, do it now.

Let's look at three simple cases to further illustrate the difference between trauma, wear-and-tear, and unusual spinal pathology:

Graham, a 22-year-old salesman, went out on the town to celebrate his football team's win. After stumbling out of a taxi at three in the morning, he somehow negotiated the nine steps that lead up to his front door. Fearing his wife's rebuke for his late homecoming, he leaned over the railing to pick a flower as a peace offering. In his drunken state he overbalanced and plummeted downwards, landing awkwardly on his back atop a box full of garden tools. He felt something crack in his spine, and experienced considerable discomfort as he crawled up the stairs. The next morning he felt very stiff, and experienced a stabbing pain in his spine with every step. His back sported a large bruise shaped suspiciously like a garden trowel.

_Deirdre_ , a 35-year-old manager, had experienced very little previous back pain. A couple of times her thoracic spine had ached during stressful periods at work, but apart from those minor incidents her back had remained healthy. During the first game of the new netball season, _Deirdre_ felt her back twinge as she lunged for a goal-saving intercept. The next morning she felt very stiff as she dressed for work. The pain continued to increase during her first sales meeting. By mid afternoon her symptoms were unbearable, and she was unable to sit for even five minutes without agonising pain. At this point _Deirdre's_ secretary drove her home and she retired to bed.

Paul is a 45-year-old engineering consultant. He is unfit and a heavy smoker. About two months ago he noticed a gnawing ache in his lower back, but as he was very busy at work he declined to see a spinal health practitioner. Two weeks later he felt some pins and needles in his left calf, but again ignored this sign as he was now even busier. Although mild, the symptoms were very persistent, and Paul could not find a position that relieved his pain. Nevertheless, by rubbing his spine with liniment and taking regular doses of aspirin, Paul could continue working. The pain gradually progressed until Paul felt it continuously, with almost no variation except after taking the pain _-_ relieving drugs. The pins and needles often _kept_ him awake at night. His wife Grace had been nagging him to seek treatment, so he finally decided that he would make an appointment _—_ when he had time, of course.

Can you deduce the type of injury with which each person is afflicted?

Graham, silly fellow, suffered a spinal trauma, while Deirdre has degeneration caused by repetitive microtrauma. Paul is the unluckiest of all—he has spinal cancer. Notice that the intensity of the symptoms does not necessarily reflect the severity of the underlying condition.

I hope that you can now see the difference between the three main causes of spinal pain. For the rest of this book, we'll concentrate on the second category, wear-and-tear, which constitutes a vast majority of all back pain cases.

Wear-and-tear can affect your spine in many different ways and places. Spinal health practitioners use many different terms to diagnose these problems. You may be told that you are suffering from a low back sprain, lumbago, soft tissue damage, a slipped disc, a touch of arthritis, spondylosis, degenerative joint disease, sciatica, a pinched nerve, or any one of a thousand other labels. What do these terms all mean?

Over the next few chapters we will look at the spine piece by piece. By examining each structure individually, you will see how wear-and-tear often affects the lower back. You will see, in an uncluttered, straightforward way, the problems that commonly afflict the spine.

The purpose of this discussion is not to help you diagnose your own problem—that task is best left to a qualified spinal health practitioner. However, you will at least develop a clearer understanding of the most often-quoted causes of spinal pain.

##  Chapter 4: Intervertebral Disc Injuries

### Middle-aged mayhem

The intervertebral discs are one of the most common causes of lower back pain. Their awkward tilted position at the bottom of the back (a legacy from our ancestral four-legged days) means that the stresses and strains of everyday life take a very destructive toll on the disc tissue.

Yet despite this anatomical vulnerability, I believe that disc injuries are frequently over-diagnosed or misdiagnosed. Unfortunately, some spinal health practitioners use 'lower disc injury' as their one and only diagnosis of back pain. Certainly, the discs in the lower back are responsible for many problems, but they are not the only cause of back pain as some practitioners would have you believe.

We will now discuss three common ways in which the disc can be injured:

(1)Disc bulging due to weakness

(2) A prolapsed disc

(3) Spondylosis.

We will also briefly discuss what effect these injuries have on the function of your spine.

### (1) Disc bulging due to weakness

Recall that the disc is composed of two main parts: a series of leathery fibrous rings called the annulus that surround a jelly-like nucleus. During your normal day-to-day activities, the jelly nucleus exerts enormous pressure on those fibrous rings. Researchers have performed experiments in which they inserted needle-like pressure gauges into the discs of some university volunteers. (Doesn't sound like much fun for the subjects, does it? I'm glad I didn't study at that particular college.) They found that even while resting in bed the nucleus created a force of about 25 mmHg inside the disc. This pressure rose to 50 while standing, 70 during normal sitting, and a staggering 200 mmHg during forward bending.

Although these forces are high, they are comfortably within the holding capability of the annulus—if it is healthy and strong. However, if the annulus's fibres weaken through wear-and-tear, then they may have difficulty in firmly containing the nucleus. The whole segment becomes unstable. Here, the pressure of the nucleus causes the annulus to bulge outwards, sometimes causing pain and stiffness.

Figure 7: A weakened annulus can allow the nucleus to bulge.

### (2) A prolapsed disc

Sometimes the annulus can completely tear, creating a channel from the nucleus to the outside of the disc. Any further strain can squeeze the nucleus from the centre to the outside of the disc, literally like toothpaste from a tube. This potentially severe condition is known as a prolapsed disc, or is sometimes called a disc herniation.

Figure 8: In the case of a herniated disc, some of the nucleus is completely squeezed out from the centre of the disc, like toothpaste out of a tube.

The squeezed-out nucleus sometimes causes a violent inflammatory reaction, which can feel like a red-hot branding iron pressing into your back. This nasty response occurs because the infection-fighting cells in your blood do not recognise the nucleus, and attack it as though it were a foreign body.

This may sound like a nonsensical thing for your cells to do. However, it makes a bit more sense if you realise that your blood stream is never supposed to have contact with the nucleus. In a healthy spine, the nucleus is wholly contained by the annulus from conception until death. However, this situation does not hold for anyone unfortunate enough to suffer a prolapsed disc, resulting in the immune system attacking the nucleus as though it were an unwelcome intruder such as a germ, or even a splinter.

The symptoms of a severe prolapsed disc can be very unpleasant: excruciating pain that accompanies every movement, severe muscle spasms, and even shock-type reactions such as profuse sweating and clammy hands. The disc sometimes impacts on other structures such as nerves, causing further problems. We will talk more about nerve injuries in Chapters 8 and 9.

Luckily, nature gave us a partial defence mechanism against disc prolapses. When we are young, the fibres of the annulus are usually strong and healthy enough to contain the nucleus, so most young people avoid the perils of a bulging disc. At the older end of life our once-jelly-like discs have dehydrated to the 'crab meat' stage. Crab meat is not liquid enough to herniate, so our senior citizens are also safe from the agony of a true disc prolapse.

However, those people in the middle - aged about 30 to 50 years - have a problem: the outer annulus fibres have had time to deteriorate, and the nucleus is still reasonably mobile. It will come as no surprise to you that this age group has the peak incidence of disc-related back pain.

Does this mean that older people do not suffer from disc-related lower back pain? Unfortunately, no. The fibres of the disc can still stiffen or become inflamed. Translated into medical-speak, this condition is known as spondylosis, which we will now discuss.

###

### (3) Spondylosis

Literally meaning 'stiff vertebrae', spondylosis is found frequently among those who are more than fifty years old. Spondylosis develops when the annulus suffers from repetitive microtrauma. Like most injuries, the annulus heals these tiny tears with scar tissue. Unfortunately, this scar tissue does not stretch as elastically as do the normal annulus fibres, meaning that the disc becomes stiffer than normal. This tightness renders the disc even more vulnerable to further microtrauma, which produces even more scarring.

After this cycle has revolved many times, the disc becomes so tight that it blocks the vertebrae above and below from moving properly. The lower back joints seize up like a rusty gate hinge. Subsequently, your back becomes inflamed, painful and generally feels stiff to move.

It's an old cliché, but the catch-cry of someone with spondylosis is that when they're bending down to tie up their shoelaces, they think "What else can I do while I'm down here"? Yes, spondylosis can make you feel very old.

The entire degenerative process can take months, years, or even decades to reach the painful stage. Like most wear-and-tear type injuries, spondylosis builds silently and painlessly, until one day an unusual activity—for example, trying (but failing) to prove to your kids that you can still kick a football, or carrying two heavy cartons of beer in from the car boot because you were too lazy to make an extra trip—provokes a more sizeable tear of the disc. Spinal health practitioners call this situation an acute-on-chronic injury, meaning that an old injury has suffered from a new tear.

As you can deduce from the above three conditions - bulging, herniation and spondylosis – disc injuries sometimes become chronic, long-lasting conditions. The vulnerability of the disc tissue, combined with the ongoing stress that we heap upon our lower backs, often produce a vicious cycle.

Later, you will learn prevention techniques and rehabilitation exercises to help heal your own disc problems and stop them from recurring. For now we will turn our attention to other frequent pain-producing structures of the lumbar spine.

##  Chapter 5: Facet and Sacro-iliac Joint Injuries

### Sprains, strains and rusty bones

Recall that the facet joints form a connection from each vertebra to those above and below, while the two sacro-iliac joints connect the sacrum to the pelvis. Problems that can affect other joints, such as ligament sprains and arthritis, can also affect these joints.

###

### Ligament sprains

Like all joints in the body, the facet and sacro-iliac joints are held together by tough fibrous ligaments. If these ligaments are subject to traumatic force, or if they are repeatedly stressed, then they can tear or weaken.

The simplest way to classify ligament tears is as a grade one, two or three. A grade one tear means that although the fibres have been injured they are all still intact, while a grade two sprain implies that some fibres have snapped. A grade three sprain is the worst, as it means that the ligament has totally ruptured.

Paradoxically, a grade two sprain is often more painful than a grade three tear. This unexpected effect occurs because a second-degree tear heals with scar tissue, which can be very painful when moved or stretched. However, a ligament with a third-degree rupture might not be able to reattach or repair itself, and so cannot produce pain as it theoretically no longer exists!

Spraining a healthy back ligament is no easy task. This injury would require a violent traumatic force, probably with an unusual direction or twist as well. However, a ligament with prior degeneration is far more vulnerable. Here, a simple action such as an incorrect lift might sprain a facet joint. Likewise, an everyday activity such as jumping off a low bench might strain the sacro-iliac joint, which normally absorbs the shearing strains and jarring forces of such an action.

What happens to your back if you sprain a ligament? The response of the back ligaments is identical to ligaments in other parts of your body: the underlying joint becomes inflamed, is painful to move, and swells (although the puffiness from sprained spinal joints is not usually visible from the surface of the skin). Think of a sprained ankle and you'll get the general picture.

When the sprain settles, two possible outcomes can lead to ongoing back pain. First, the thickening and tightness of the scar tissue make the whole joint stiff and immobile. Conversely, the ligament may not knit tightly enough, meaning that the joint becomes loose and unstable.
If your back joints become either stiff or unstable, then the potential for future wear-and-tear is increased. Naturally, each type of injury requires a different approach to achieve its best resolution. We will discuss the subjects of joint stiffness and instability in detail later as they are very important concepts to your understanding of back pain.

### Coccydynia

This condition, with the wonderful sounding name of cox-ee-din-ee-ah, is the common term for a sprain of the ligaments that hold the coccyx to the sacrum. As the coccyx no longer has a real function and does not bear any weight, it rarely suffers from degenerative injuries. Due to its sheltered position, there is only one way that you can sprain it: by falling onto a hard surface and landing on your bottom. Ouch!

Many years ago, surgeons decided that as the coccyx was a rather useless piece of bone they might as well just remove it from anyone suffering with pain in this area. Coccygectomy, I believe, was the medical term for this procedure. However, they soon noticed an unexpected result: about three-quarters of their patients were experiencing just as much pain in their coccyx as before, even though the bone was in a jar on their mantelpiece. How could this be? The answer will be revealed in chapter 9. Hint: It has something to do with the nerves.

###

### Arthritis

Arthritis is common in the sacro-iliac joint and facet joints in the spine. The discs and vertebrae are also frequently diagnosed with arthritis, which is another way of saying advanced spondylosis.

Very few concepts in medicine are misunderstood as frequently as is arthritis. Mountains of misinformation, half-baked opinions and bad advice have confused the truth about what is really a remarkably simple condition.

I'll be straightforward. Arthritis is simply wear-and-tear of a joint.

Pretty boring, heh? Just plain old wear-and-tear, not the lifelong agonising condition that the word 'arthritis' conjures up in most people's minds. Sure, some people have a genetic predisposition to developing arthritis. But for most people, arthritis is simply wear-and-tear that was left unchecked.

To further understand the meaning of arthritis, let's do what medical people do, and break the word into its Latin (or was it Greek? – I really don't know) roots. The first part, arth, means 'joint'. For example, an arthroscopy means 'to look into a joint'. The second part of the word, itis, means 'inflamed'. An inflamed appendix is therefore known as appendicitis, an inflamed pharynx as pharyngitis while inflamed tonsils are called . . . I'll let you guess.

Put these two bits, arth and itis together, and they mean simply 'inflamed joint'. So how does the joint become inflamed? Through wear-and-tear, of course. I hope that you now understand that arthritis is simply joint wear-and-tear resulting from years of accumulated microtrauma. Got it? Good. Now, I'm going to confuse you a bit.

In this discussion, I am referring to the common condition of _osteoarthritis,_ which commonly affects the spine, hips and knees. However, there are about 150 other sorts of arthritis that fall into a completely separate category. Some of their complicated names include Ankylosing Spondylitis, Juvenile Chronic Arthritis and Rheumatoid Arthritis. In contrast to normal osteoarthritis, these conditions are diseases and can usually be detected by means of a blood test.

The symptoms of these other arthritic diseases vary. Some of them are associated with skin rashes, lumps and bumps, while others cause generalised aching and stiffness. The pain associated with these diseases ranges from boring aches to a complete severe crippling of all the joints. But don't fret: most of these diseases are rare, and many, such as rheumatoid arthritis, do not usually affect the lower back.

If you have one of these conditions then you should still uphold the principles of back care described in this book, but be aware that your condition also requires specialist management.

Whenever I diagnose someone as suffering from spinal wear-and-tear, I avoid using the word 'arthritis', as it is too easily confused with the above conditions. Why use an ambiguous term when 'degeneration' or 'wear-and-tear' are less confusing and more descriptive? So for the rest of this book, the word 'arthritis' will refer to normal, common osteoarthritis, not its more sinister namesakes. Let's now take a closer look at other aspects of this much-misunderstood condition.

Osteoarthritis is not caused by age. Sure, it's far more common in the elderly population, but it is definitely not a direct consequence of age. For example, some people have arthritis in one knee, while the other is fine. Yet both their knees are the same age, aren't they?

A characteristic of arthritic joints is that they sometimes make creaking, scraping noises as they are moved. The medical term for this noise is crepitus. Feeling or hearing coarse crepitus can make your neck hairs stand on end, just like when someone scrapes their fingernails down a blackboard, or rubs two pieces of Styrofoam together. (Can you hear it? Just the thought makes me shiver.)

The crepitus sound originates from the lining of cartilage that covers each joint surface. Normally, this cartilage is oily and smooth, which facilitates the gliding of the joint surfaces over each other. However, the wear-and-tear associated with arthritis makes the cartilage rough and ragged, which can produce a sandpaper-like crunching sensation when the joint is moved. In short, the joint surface gets rusty.

If the wear-and-tear continues unchecked, the two joint surfaces grind each other away. Small flakes of bone and cartilage crumble off, and generally float around the joint cavity making a nuisance of themselves. Eventually the arthritis can completely denude the joint surfaces of the silky-smooth cartilage, meaning that the bones must glide on each other's rough, chalky surface. At this point the joint becomes extremely stiff and painful, and will possibly swell.

Please, for the sake of your spinal health practitioner's sanity, seek treatment before your joints deteriorate to this point.

Previous joint injuries, particularly those that heal too loosely or stiffly, can predispose you to 'arthritis' later in life. This susceptibility can also occur following disc-related injuries, as the nucleus is less effective at absorbing and dissipating shock, meaning that the facet and sacro-iliac joints have an extra burden to bear.

Furthermore, a previously injured disc sometimes loses height, particularly if the nucleus herniated. If the disc is too low then the vertebral bodies sometimes rub together. Just as a builder's thumb develops a callous to protect it from the constant friction of work tools, the vertebral body responds to this frequent rubbing by developing extra layers of calcium.

Eventually the extra calcium forms a ridge of growth known as an osteophyte. These bone callouses are not intrinsically painful, but they can cause plenty of trouble if they impact on other pain-sensitive structures such as nerves.

Figure 9: In this picture, the upper level is normal. However the lower level has a degenerated disc and an arthritic facet joint. Note the little bony outgrowths—the osteophytes—which can push on other structures such as nerves, causing lots of pain.

Once the degeneration has progressed to this stage it is usually visible on x-ray pictures. Despite this fact, it is very misleading to diagnose arthritis using x-rays alone, which is, unfortunately, common practice. So why is it wrong?

Consider a typical case in which the patient has been experiencing pain for, say, two weeks. Upon sighting the degeneration on the x-ray, the patient is usually told that they have the dreaded affliction of arthritis, and are often informed that they will 'just have to learn to live with it'. This bad advice is often reinforced with fallacies such as 'you're just getting old', and 'treated' with handfuls of pain-killing tablets.

But consider this point: the facet joints and discs take years, even decades, to degenerate. The x-ray would have looked practically identical had it been taken a month previously, despite the pain only being present for about two weeks. It follows that if the joints and discs could be returned to their condition of a month previously, then the pain should disappear, although the 'arthritis' still shows on the x-ray.

The joint wear-and-tear associated with arthritis can be likened to a surgical incision in the skin: the scar may be present many years later, but it does not necessarily cause any pain or stiffness. Likewise, arthritis is not necessarily permanent. If the joint movement can be returned to normal then the pain, inflammation and stiffness should disappear, even though the degeneration is present in the spine.

Furthermore, one study showed that 98% of healthy 60+ year-olds have some degree of arthritis in their spines, even though they feel no back pain whatsoever.

In short, please don't worry if your x-ray shows some arthritis, and don't treat arthritis as an incurable condition. It is simply advanced wear-and-tear of a joint or disc. Osteoarthritis is not a disease of the whole body, and as such there will never be a magic cure. Trying to develop an arthritis pill is as silly as producing a 'sprained ankle pill'. However, with sensible management, exercise, treatment and prevention, the symptoms of arthritis can usually be reduced or even eliminated.

##  Chapter 6: Injuries to the Vertebrae

### My bones are broken?

It may surprise you to learn that the vertebrae themselves rarely cause lower back pain. These sturdy bones are well cushioned by the discs, and held firmly in place by many ligaments that stretch between their bony arms. However they are not totally innocent of all charges: occasionally things can go astray with the structure of the bones themselves, leading to various pain-producing conditions.

For example, the entire vertebral body can suffer with a crush fracture, which we'll talk about later in the chapter. For now, we'll talk about another pair of related conditions that can affect the bones: stress fractures and displaced vertebrae.

These two disorders have the most confusing official names in all of physical medicine. They are respectively named spondylolisis and spondylolisthesis. As you can imagine, these terms sit confusingly beside 'spondylosis', which we discussed earlier. If you're not yet confused then throw in spondylitis, which refers to inflamed vertebrae.

Spondylosis, spondylitis, spondylolisis, spondylolisthesis . . . sorry, I needed months of study at university to remember these names, so I was determined to use them at least one more time before we pack most of them away for the remainder of the book.

Just for fun, why not try to remember those terms to throw at the next person who gives you unwelcome advice about your sore back.

###

### Stress fractures (Spondylolisis)

Some patients are horrified when they are diagnosed with a vertebral stress fracture. Judging from their aghast expressions, visions of life in a wheelchair flood instantly to mind. If you have a spinal stress fracture then do not fear, for the chance of paraplegia is negligible and need not concern you. In a fracture of this type, the ligaments, discs and muscles remain intact, and provide ample support to prevent any such catastrophe.

A stress fracture, by definition, is a break in the bone that occurred without trauma. It is a classic example of the devastating effects of accumulated microtrauma. Of course, vertebral fractures can occur in accidents as well, in which case they are likely to have consequences that are more serious. As traumatic spinal fractures require specialist help, we won't be discussing them in detail.

The most common site for spinal stress fractures to develop is in the vertebral arch of the bottom two vertebrae. In particular, the point between the upper and lower facet joints is the most vulnerable area.

As stress fractures usually develop gradually, most victims do not even realise that they are occurring. The back may issue some warning signs that the fracture is increasing—such as pain following activity—while sometimes the pain can start seemingly out of the blue.
Two main factors predispose your spine to stress fractures.

(1) The movement of lumbar extension: i.e. bending backwards, especially if this movement is combined with twisting or sideways tilting.

(2) Jarring, jolting or heavy-impact forces.

When these causes occur together—a jarring force while the spine is positioned in extension—massive tension is created on the vertebral arch. If the extension and jarring are repeated many times, the bone starts to weaken, and can ultimately break.

Because of these predisposing fractures, stress fractures are far more common in sports people than in the general population. Activities such as gymnastics demand a high degree of lumbar extension combined with jarring. Try to envisage the huge spinal stress when those young girls do that backward flip-flop thing.

Kicking a football, weightlifting, track and field sports such as long and high jump, surfing, serving a tennis ball and diving also place similar high-risk demands on your lower back. Perhaps the most demanding of all is fast bowling in cricket. These types of activity—spinal extension, especially if combined with a half twist, superimposed with a heavy jarring force and repeated often—are a common recipe for a stress fracture.

###

### Displaced vertebra (Spondylolisthesis)

You might have heard the term 'slipped disc' being used to describe back pain. This term has no medical meaning, and is simply a common expression for a bulging or prolapsing disc. When talking here about a 'displaced vertebra' I am referring to an entirely different condition.

A displaced vertebra occurs when a bone, usually one of the lowest two lumbar vertebrae, slides forward over the bone below. Please note that these slips are never sudden events, and are not accompanied by pain, clicking, clunking, or any other sensation.

Figure 10: A displaced vertebra (spondylolisthesis). Believe it or not, but this injury is usually painless.

Is a displaced vertebra painful? Well, funnily enough, no. The bones themselves don't cause much pain. Many people with a displaced vertebra go about their business—playing sport, dancing in nightclubs, jumping out of planes (with a parachute), whatever—blissfully unaware that their bones are not aligned with each other.

The displaced vertebra sometimes causes pain by pressing on other sensitive structures such as nerves or ligaments. It also causes problems because the adjacent discs and facet joints degenerate more rapidly than usual. Without the support of each other, these structures quickly become overworked. Lucky they don't belong to a union!

Displaced bones occur for three main reasons: either a breakdown of the vertebral arch, a natural birth defect, or severe degeneration.

#### A BREAKDOWN OF THE VERTEBRAL ARCH

If the vertebral arch breaks down on both sides (as in the picture above) half of the bone structure separates from the main body of the vertebra. Influenced by the inward curve of the lumbar spine, gravity gradually pushes the vertebral body forward. This type of slip usually occurs during early childhood, and is remarkably painless. Once growth has ceased, the bones don't go anywhere in a great hurry.

#### NATURAL BIRTH DEFECT

Some people are simply born with wonky or incomplete vertebrae. This defect allows one bone to move forward on the other, usually in the toddler stage of life. As with type one, this type of slip almost never progresses in adult life.

#### DISC AND LIGAMENT DEGENERATION

If the discs and facet joints have severe degeneration then they may not be strong enough to withstand the ordinary strains of gravity. The pressure slowly stretches and elongates the ligaments and discs until they are too loose to effectively stabilise the vertebra. This laxity then allows one bone to gradually slide forward on the next, leading to the 'displaced vertebra'. The slippage usually takes place over several years. They often slowly worsen, but never slip suddenly.

###

### Crush Fractures

The term 'crush fracture' is wonderfully descriptive, isn't it? Simply, it refers to a condition in which the vertebral body is crushed, so it fractures. Just this once I wish that some whiz-bang medical expert would invent a more complicated name so that we spinal health practitioners could sound more intelligent when diagnosing this condition.

Like all broken bones, vertebral crush fractures are sometimes caused by violent trauma. However, most crush fractures are associated with osteoporosis, a condition in which the bones become very weak and brittle.

The highest risk group for osteoporosis, and thus vertebral crush fractures, is elderly women. Almost one-third of all women over the age of sixty-five have a vertebral crush fracture. This condition varies in severity from a localised dint in the end of one vertebra to a complete collapse of a whole row of bones.

A series of stress fractures can alter the curve of the spine. A _dowager's_ hump, a hunchbacked posture which is associated with osteoporosis, is an extreme example.

A spine with multiple crush fractures will usually be painful and extremely stiff. However, as with spinal stress fractures, many people function perfectly well with one or two minor crush fractures. In the Appendix we will talk more about the risk factors, treatment and prevention of osteoporosis.

##  Chapter 7: Muscle Injuries

### No such thing as a torn back muscle?

If disc injuries are the most over-diagnosed lower back complaint, then muscle tears run a close second. I believe that many people are erroneously diagnosed as having a back muscle problem when they are suffering from a disc or joint injury. Perhaps this mistake occurs because the pain associated with many lower back injuries is often perceived as arising from the muscles.

Why are back muscles so rarely injured? There are three simple reasons. First, muscles are, by nature, very adaptable. In contrast to most other back structures, the muscles tend to strengthen, not degenerate, with repeated or heavy use. Second, most back muscles are long and elastic, and are thus able to stretch a considerable distance before they tear. By contrast, the ligament and disc fibres are very short, and tighten long before the muscles reach their limits of extensibility. Third, muscles are very robust. Enormous force is required to tear a muscle, which would no doubt tear many other structures as well.

Also, consider that the signs of a true muscle tear—severe bruising and swelling—rarely, if ever, occur in a non-traumatic lower back injury. If your spinal health practitioner diagnoses you as having a back muscle strain then he or she is probably, in my humble opinion, misdiagnosing another injury.

However, muscles can contribute to your pain in four instances that we'll now examine: bruising, spasm, post-exercise soreness, and 'trigger points'.

###

### Bruising

Back muscles, like all other structures in the body, can suffer from bruises and bumps. Under normal circumstances a bruise will always be traumatic, and will be recognisable from the history of the injury. This type of injury is usually confined to the football field or other similarly violent situations.

The medical term for a bruise, haematoma, infers that the symptoms of bruising arise from broken blood vessels—the arteries and veins. The amount of bluish discolouration does not always represent the severity of the underlying bruise, but simply reflects how much blood escaped from the tiny blood vessels before they clotted.

###

### Spasm

All muscles in your body can be roughly divided into two groups. The characteristics of these groups vary in many ways, one of which is their response to the injury of a nearby joint: one set of muscles weaken, while the other group tend to spasm in the same situation.

Some lower back muscles, particularly the large, surface muscles, belong to the group that go into spasm. In particular the paravertebral muscles, which run down the length of your vertebral column, tend to automatically tighten if you injure your lower back.

Despite being frequently diagnosed, muscle spasm is not a primary cause of lower back pain. It is a response to other injury; muscles don't decide to spasm by themselves! To relieve the pain associated with muscle spasms, the joint structures that caused the original pain must be addressed. Working on the muscle in isolation from the underlying problem will have very little lasting benefit.

###

### Post -exercise soreness

Like all muscles in the body, back muscles can become sore and inflamed from overuse. If you play a rugged five-setter of tennis, followed by a session at the gym and then chop enough firewood to last until the end of winter, don't be surprised if your muscles become a tad sore. The peak discomfort from this type of problem is usually about one or two days later.

###

### Trigger Points

A trigger point is a small, localised thickening in a muscle, which is commonly known as a 'knot'. These knots develop in response to unremitting, long-term overload that can be due to many factors such as weakness or poor posture. Excessive demand can also come from frequent overuse, like a job that requires repetitive bending.

The condition of nearby joints also affects muscle knots. As mentioned above, an injury will cause the nearby muscles to react with either spasm or inhibition. If a joint is chronically or repeatedly injured, then the nearby muscles will constantly be irritated into spasm or inhibition. After days, weeks, or even years of this constant irritation, the muscle responds by developing trigger points in its most sensitive areas.

Trigger points tend to develop in the area that the main nerve fibres enter the muscle belly. This point is naturally more excitable than the rest of the muscle, and so is prone to produce a localised knot. Once they have arrived, trigger points behave like a bad guest and overstay their welcome. They can even refer pain to other areas of the spine or legs, and sometimes mimic other conditions.

Some people find that a deep massage helps to relieve their lower back pain. Often the relief is due to the relaxation of spasm, or the release of tension from trigger points. Unfortunately, the massage does not change the reason that the spasm or trigger points initially developed, so the pain returns. When dealing with muscle-related lower back pain, you should try to correct the underlying factors if you wish to fully cure the problem. As you will learn as this book progresses, massage alone is a poor way to treat lower back problems.

But ignore that last paragraph if you can persuade someone to give you a pleasant, relaxing back rub. It's probably not going to do you any harm, and, if it feels good, why not!

##  Chapter 8: Referred pain

### Is your back problem getting on your nerves?

Nerves injuries and referred pain are the most complicated and confusing areas of lower back pain. However, as you've already survived the spondylosis-spondylitis-spondylolisis-spondylolisthesis bit, I reckon you've got a fair chance of emerging unscathed by the ruthless complexity of nerve injuries.

Don't feel worried if you find this section difficult at first. Even many spinal health practitioners misunderstand the ins-and-outs of nerve injuries for the simple reason that they are so complicated. So just try to get a general feel for their nature and behaviour. As the next two chapters unfold you will see how many common conditions, not only in your spine, but in your limbs as well, are caused by nerves. Let's now demystify this complex and rapidly developing area of spinal health care.

###

### Normal Nerves

Nerves have two main jobs:

(1) To carry signals to the muscles to make them contract

(2) To carry sensory signals up to the brain. These signals include sensations such as touch, warmth, vibration and pain.

Suppose you wish to move your big toe. Your brain sends a signal, which is like a mild electric current, charging down your spinal cord. The spinal cord is protected not only by the vertebrae, but also by a sheath of tough fibrous tissue that looks like an elongated sock. This canvas-like sheath is called the dura.

Most non-medical people have never heard of the dura, which is surprising, as it is a frequent cause of back pain and stiffness. If you would like to know what the spinal dura feels like, then find a newborn baby and poke your fingers gently around the top if its head. Eventually you will feel a soft spot, just above its forehead, that has no bony covering. (This hole gradually closes over during the baby's first year of life.) If you push gently into this hole, you will not only send the baby's mother into hysterics (don't worry, if you're gentle you won't hurt the baby at all) but you will feel a firm, canvas-like structure under your fingers. This is the dura around the baby's brain, which is continuous with, and very similar to, the spinal dura.

So the dura covers the brain then extends down over the spinal cord, resembling what I imagine a tadpole's body suit would look like. At the other end, the dura attaches onto the coccyx, that tiny bone at the bottom of your sacrum. If your dura is not moving properly you might feel pain at this attachment point. This syndrome can cause the symptoms that fooled those knife-happy, coccyx-removing surgeons that we mentioned in Chapter Five.

When the electrical signal reaches the appropriate level of your spine, it branches sideways from the spinal cord along a small filament known as a nerve root. Next to the nerve root is another similar nerve root, which carries signals in the opposite direction. The two nerve roots function like opposing lanes on a highway, allowing the signals to travel in different directions without colliding.

Just as the two little nerve roots emerge from the protective covering of the dura, they combine. At this point the nerve technically becomes known as a spinal nerve.

Figure 11: The spine in cross section.

There's a lot to learn in the above picture, isn't there? Let's start in the middle. That roundish, lumpy-shaped thing is the spinal cord. Those two stringy bits poking out each side are the nerve roots: the top one transmits the sensory signals, while the lower one delivers outgoing orders to your muscles. Encapsulating this whole area is the canvas-like spinal dura. You can also see the two pairs of nerve roots combining to form the spinal nerves, which exit the vertebral column through small tunnels.

Whew! If you understand all of this, then you are halfway to becoming a decent spinal health practitioner.

The spinal nerve then leaves the protected sanctity of the spinal cord tunnel through a hole known as the intervertebral canal. These canals are formed on one side by the facet joint, and on the other side by the disc. We'll see later in the chapter how this area is a frequent site for nerve-related injuries.

Once they have passed through these small canals, the spinal nerves form a tangled mishmash of webbing. They emerge on the other side of this fishnet-type structure as peripheral nerves, which then travel to the trunk, hips and legs. From now on, we'll refer to 'peripheral nerves' as just good old 'nerves' for simplicity.

Are you keeping up with me? I hope that all of this complicated talk of dura, nerve roots, spinal nerves and peripheral nerves is not getting on your nerves. (Boom tish!)

Each of us has about half a dozen main nerves that travel into the legs. We'll conveniently ignore most of them, although I couldn't sleep properly at night if I didn't at least mention two: the femoral nerve and, importantly, the sciatic nerve. These two nerves are often accomplices in lower back pain. The femoral nerve travels down the front of your thigh to your knee. In contrast, the sciatic nerve travels through your buttocks and down the back of your thigh.

Many people misunderstand the nature of nerves. Just for fun, try the following one-question quiz.

Q1. The sciatic nerve is as thick as . . .

(a) A delicate strand of a spider's web

(b) A human hair

(c) A strand of knitting wool

(d) A drinking straw

(e) Your little finger.

If you said (e), then congratulations! You have passed this test with the incredible grade of 100 per cent. However, if you answered with one of the first four options, do not fret, for most people are like you and underestimate the robust nature of the nerves. They are not delicate, fine little things, but are tough, fibrous, rope-like structures.

I hope that you now have a rudimentary understanding of the workings of a normal nervous system. I realise that the subject is complex; you've done very well. Take a deep, relaxing breath, because now we'll turn our attention to a more specific topic: nerve injuries.

###

### Compressed Nerves

Compressed nerves are a frequent consequence of spinal injuries. A nerve can be compressed when any structure— a bulging disc, a swollen joint, even a cancerous tumour—pushes into it anywhere along its path. Spinal health practitioners refer to compressed nerves using a variety of names, including 'pinched nerves' and 'referred pain'. These terms are generalisations that imply roughly the same thing, although you will soon see some subtle differences between them.

One tag that many spinal health practitioners apply to back-related thigh pain is the term 'sciatica'. This diagnosis implies that the sciatic nerve is being compressed by a disc as it exits the lower back. You will soon see that this is a very poor description of what really happens. By the end of the next two chapters, you will see that there are many more accurate ways to describe causes of back-related leg pain.

You will also learn how compressed nerves can cause a variety of other unpleasant symptoms in your legs such as tingling, numbness and weakness. You'll also be surprised to discover that compressed nerves can cause seemingly unrelated signs, such as stiffness, tenderness, and even swelling.

Theoretically, any structure in the lower back can compress a nerve. However, if we follow the path of the nerve from the spinal cord to the limbs, we come across three places that they are particularly vulnerable:

(1) Inside the spinal cord tunnel

(2) As they pass through the intervertebral canal, and

(3) Where the nerves rub against other structures.

Let's look at the implications of these three common points of nerve compression. Don't worry if you can't remember the exact details of every condition, just try to develop a feel for the general nature and importance of nerve injuries.

#### INSIDE THE SPINAL CORD TUNNEL

The tunnel through which the spinal cord travels does not have very much spare room, as the spinal cord takes up at least half of the area in most places. If a bulging disc protrudes into this otherwise almost impenetrable area, it quickly encounters the dura—that long, canvas-like sock of tissue.

The dura is a bit of a sook when it is pushed around, as it is used to being protected within a very sheltered environment. So the pressure of the disc quickly causes the dura to become inflamed and tender, in much the same way that soft hands develop a blister more quickly than roughened, callused palms. The result is widespread pain, which is highlighted by any movement that moves the dura or stresses the disc. Bending forward is a classic example.

Figure 12: Here, a bulging disc is pushing onto the spinal dura, which is likely to cause its owner pain and stiffness.

A severely prolapsed disc can also cause two other nerve-related problems inside the spinal cord tunnel. These conditions are called central stenosis and nerve root compression.

##### Central stenosis

'Stenosis' means 'narrowing'. A diagnosis of central stenosis means that the tunnel through which the spinal cord travels has become narrowed. This narrowing, especially if it is due to a disc prolapse, can be serious, as it presses on the spinal cord.

The consequences of untreated central stenosis can include severe pain, pins-and-needles, and gross muscle weakness. You may be suffering from central stenosis if you have any of the following three symptoms:

(1) Pins and needles in a 'sock' distribution (a 'glove' distribution may occur if the stenosis is higher in the spine)

(2) 'Saddle paraesthesia' i.e. pins and needles in the genital region, combined with an inability to pass urine or defecate correctly

(3) Uncontrollable spasms in the leg muscles.

This condition is a distant cousin of paraplegia, and requires specialist assessment and treatment. If you have any of these signs then please don't mess around. Make an appointment with your spinal health practitioner today.

##### Nerve root compression

The second possible outcome of a severe disc injury occurs when the nucleus pushes onto the nerve roots—the small pair of filaments that emerge from the spinal cord. The nearest nerve root to the disc is the one that carries signals to the muscles. If this nerve root is compressed the muscle-bound messages are interrupted, causing weakness in the legs and feet.

These symptoms generally indicate severe damage, so you should ensure that any weakness or clumsiness in your legs or feet is thoroughly investigated. Tripping over a loose floor mat or a low step is the first thing that patients notice.

Luckily, the nerve root that carries the sensory signals up to the brain is a long way forward in the spinal canal, so even severe disc problems do not normally reach the sensory nerve root. We are spared what would doubtless be extraordinary pain.

Figure 13: Here, the nucleus of the disc has prolapsed so badly that it is pressing not only on the dura, but onto the motor nerve root as well. As you will see in the next chapter, this type of problem can cause not only pain, but weakness in the leg muscles as well.

Luckily, both central stenosis and severe nerve root compression are rare. However, compression of the dura is far more common, and is one of the most likely consequences of an unstable disc.

#### IN THE INTERVERTEBRAL CANAL

The intervertebral canal is a bit like Uganda in the 1970s or Afghanistan in the 1990s: it is a very dangerous place through which to travel. These narrow pairs of holes are formed by the discs on one side, the facet joints on the other, with bone on the top and bottom. Injury to any of these structures can therefore press on the spinal nerve.

For example, the inflammation that follows a facet joint sprain can swell into the intervertebral canal, pressuring the spinal nerve. Or a disc can bulge or prolapse into the canal, leading to nerve-related pain.

Chronic problems, such as arthritis, can also create havoc in the intervertebral canal. As the joints or discs degenerate, osteophytes (calcium deposits) can accrue on their edges. As these calcium deposits increase in size, they can encroach so far into the canal that the nerve has very little room through which to pass. Even simple movements like walking cause pain.

When the intervertebral canal is severely narrowed in this way, it is called intervertebral stenosis. This condition, in which the bones themselves are effectively squashing the spinal nerve, can be difficult to cure. Note that although this name is similar to 'central stenosis', these two conditions have different ramifications.

Figure 14: Two things are wrong with this vertebra. On the left side of the picture, the facet joint is swollen, which encroaches into the intervertebral canal from the top. On the right side, the vertebral body has developed bony spurs – osteophytes – which are also intruding into the intervertebral canal. Either of these two injuries can cause pain and stiffness by itself. However, when they occur together on the same side, the intervertebral canal becomes severely narrowed, and the spinal nerve has very little room to move. This condition is known as _intervertebral canal_ _stenosis_.

So you can see that many lumbar structures—including not only the discs, but also the joints and even the bones—can compress the spinal nerves in the intervertebral canal.

#### WHERE THE NERVES RUB AGAINST OTHER STRUCTURES

Many different structures can compress the nerves as they travel through the hips and limbs, including old injury sites, natural bony attachments, and branches at which the nerves divide. I won't list all the common sites here, as that would involve about a hundred ten-syllable words that would doubtlessly make excruciatingly boring reading. Instead, I will illustrate this concept using a single example.

You have a small muscle in your buttocks called the piriformis. In many people, the sciatic nerve pierces directly through this muscle, rather than running alongside it. Guess what happens if the piriformis muscle gets tight, or if it goes into spasm? That's right—it clamps around the sciatic nerve. This causes pain, tightness, and all of the other symptoms associated with compressed nerves. This set of symptoms occurs commonly enough for it to score a name all of its own: piriformis syndrome.

Figure 15: A view of your pelvis from the back. This illustration depicts a case of piriformis syndrome, which can, for reasons that should now be obvious, be a real pain in the butt!

In summary, we have seen three places in which the nerves are frequently compressed: inside the spinal cord tunnel, as they pass through the intervertebral canal, and where the nerves rub against other structures. By combining this knowledge with the earlier discussions about anatomy and joint movement, you should now be starting to get a feel for the myriad of ways in which referred pain can be generated.

Nerve compression can produce a wide range of symptoms, including pain, weakness, and stiffness. Next we'll look at these symptoms to discover the surprising characteristics and origins of each condition.

##  Chapter 9: Consequences of nerve compression

### Pain, pain, pain and more pain—oh, and some weakness and stiffness as well

Anyone who has ever suffered from a compressed nerve can attest to the most common symptom: pain. However, nerve-related pain is unusual because it varies wildly in its character. Furthermore, nerve compression pain often appears in seemingly unrelated areas that are far removed from the source, and often trick you into thinking that you are suffering from another injury.

In the first part of this chapter, we are going to explore why nerve injuries have such different presentations, and why the pain refers such a long way from its origin. After that, we'll look at two other consequences of nerve injuries: muscular weakness, and nerve immobility.

###

### Pain

#### DIFFERENT TYPES OF PAIN

The signs and symptoms of a sprained ligament or torn muscle are readily identifiable and consistent, but the symptoms of back problems vary wildly. They range from dull gnawing aches to sharp shooting pains, and even sensations such as pins-and-needles or numbness. Sometimes they make your legs feel tender, or overly sensitive. Why do nerve injuries provoke such a seemingly unrelated variety of feelings?

The reason that nerves produce such assorted symptoms is that different parts of the nerve can be injured. Each nerve is composed of two parts in much the same way as an electrical cable is made from a metallic wire with a rubberised coating. In your nervous system, the parts that carry the signals are called the neurones. The outer protective covering is called the connective tissue.

Either part can cause pain if it is compressed. Furthermore, the whole nerve itself can become inflamed and painful if it is compressed for a long period. Let's have a brief look at each of these three possibilities. However, please be aware as you read that, like most back pain diagnoses, these conditions are not necessarily clear-cut, isolated situations. They can, and often do, overlap.

##### Referred pain from the connective tissue

When a structure such as a ligament or muscle is injured, you feel pain because the local nerve endings register a painful stimulus. This message goes along the nerve and into the spinal cord, which forwards it to the brain.

So what happens when the outer, connective tissue part of nerve is compressed or injured? Exactly the same thing, for the nerves have a nerve supply too! The feeling of a connective tissue injury is readily recognisable to most people: a deep, aching, familiar type pain. Often the pain is diffuse, and is sometimes described as 'like a toothache'. In short, an injury to the nerve connective tissue feels very similar in character to most other sprains and strains.

However, injury to nerve connective tissue—which, by the way, includes the dura—has one minor difference. Most nerves have a very diffuse nerve supply, so the brain cannot always localise the exact source of the problem. The result is that the brain often misinterprets the painful signals, incorrectly 'guessing' their source. You experience the pain in the 'wrong' area. These misguided symptoms are simply known as referred pain.

This inaccuracy on your brain's part is not surprising—no offence intended. The poor thing is being continually bombarded by signals from all over the body, and cannot be expected to monitor every square millimetre with unerring accuracy.

Think of this misinterpretation as similar to the brain trying to place the source of an aroma. Upon first sensing the smell, your brain may be able to roughly tell you what is causing it—say, a freshly baked apple pie. However, you probably would not be able to discern the exact location of the pie as your sense of smell is too diffuse. You would probably just surmise that the pie was in the kitchen. In the same way, your brain can tell what type of sensation is coming through the nerve—pain—but cannot always pinpoint its exact location.

##### 'Nerve pain' from the neurones

The second major type of nerve pain arises when the neurones are injured \- in other words, the signal-carrying part is compressed or somehow strained. This situation produces an entirely different character of pain from connective tissue injuries.

Normal neurones carry their signals using a series of chemically generated electrical impulses. If the neurone is compressed, false electrical signals are created. Your brain cannot distinguish from where, how or why the false signals arose. This results in pain or other sensations that appear in distant areas.

Imagine that you are chatting on an old-style landline telephone to your aging Aunty Doris, who lives on the other side of the country. Halfway through the call, a linesman working down the street clamps some electrodes onto the telephone lines, and, unbeknownst to you, he uses some technical equipment to join the conversation. You would find it impossible to discern the location of the linesman. Your brain would simply make its best guess, and assume that the new signal was coming from its usual source: Aunty Doris's bedroom telephone. Gasp! Does she have a new toy boy?

Likewise, an injury to the neurones will create a whole new signal. This strange message will then travel up the rest of the neurone in the normal way, making it impossible for your brain to place its origin, or even to discern its intended meaning.

Neurone-related symptoms are called dysesthetic pain, (dis-ess-THET-tick . . . try not to lisp) which means 'pain that does not feel normal'. Dysesthetic pain is often a stabbing, burning or electric sensation. Other words sometimes used to describe neurone-related nerve pain include 'searing', 'crawling' or 'jabbing'. These symptoms can be very disturbing, as they are unfamiliar to most people.

Neurone injuries can also give rise to two other symptoms: _paraesthesia_ , or pins-and-needles, and anaesthesia, or numbness. I find it amusing that the term 'anaesthesia', which is difficult to pronounce, hard to spell and poorly understood, has more letters than a good old-fashioned word like 'numbness'.

In short, neuron injuries produce weird, unfamiliar symptoms.

##### Inflammation of the whole nerve

Normal nerves have two systems that keep them healthy. The first system uses a thick liquid that slowly circulates around the nerve, which delivers the chemicals that allow it to fire its electrical impulses. The second system that keeps the nerves functioning is a very rich and elaborate blood supply. The nerve system is a real hog for oxygen: it consumes 20% of the available oxygen in your blood, despite only weighing about 2% of your entire body mass.

If the nerve is compressed, then the flow of the fluid and blood supply is retarded, meaning that the nerve cannot fire properly. This misfiring produces pins-and-needles. To show how easily this occurs, just sit on your hand for twenty minutes or so and see what happens.

If your nerve is compressed for a long time – for example, an hard osteophyte pressing on it in your spine - then its blood supply dwindles, causing your nerve to swell. It can sometimes become so tight that even your blood cannot force its way in, and, deprived of oxygen, your nerve starts to die. Despite initially being healthy before it was compressed, your nerve now has its own problems. It then feels tender and inflamed along its length. These symptoms are frequently misdiagnosed as tendonitis, RSI (repetitive strain injury) or chronic muscle strains.

#### AREA OF PAIN

We have seen how nerve injuries can vary in character, from dull aches to localised pins-and-needles to distant inflammation and tenderness. But why do we feel these symptoms in such strange and seemingly unrelated areas? The answer to this question varies according to which section of the nerve was affected.

The nerve roots have specific distribution areas known as dermatomes. Pictured below, the sites of referred pain or other symptoms correspond to which segment of your back is injured.

Figure 16: This picture shows the areas to which each nerve root normally refers. These areas, known as 'dermatomes', can be very handy in helping to localize the source of your problem. For example, can you see that if you had pain or pins-and-needles in your big toe and outside of your lower leg, then it would most likely be arising from your L5 nerve root?

You can see from the diagram that an injury that compresses a thoracic nerve root is likely to cause pain in the chest that resembles a lung or rib problem. The L1 nerve refers lower abdominal pain, mimicking appendicitis or a hernia, while an L2 injury can appear as a hip joint strain or groin muscle tear. The L3 and L4 refer respectively to the front and back of the thigh, tricking the unwary into believing that they have a quadriceps or hamstring muscle strain. Note that L5 sometimes produces no pain in the back or thigh, only in the calf and foot region. This tricks many people with an L5 injury into thinking that they have a leg problem. Finally, the first two sacral nerve roots create pain down the back of the legs. Can you see how easily a spinal problem can fool you into believing that you have another injury?

An injury to the dura produces pain that roughly corresponds to the dermatomes above, but the pain tends to be more diffuse. Generalised pains in the back, buttocks or legs can often be attributed to a dural injury (see diagram).

Figure 17: On the right is a typical pain pattern that would arise if your dura was compressed at a low spinal level – say at the L5-S1 area. This pain feels vague and deep. The left side of the picture shows a typical referral pattern from an injured lower disc. Note that this pain is not caused by a compressed nerve, but is simply your brain misinterpreting the source of the pain.

Enough talk of pain! Let's now look at the two other main consequences of nerve compression: weakness and nerve immobility.

###

### Weakness

Recall that the nerve root nearest the disc carries the signals to the muscles to make them contract. Compression of this nerve root will cause weakness in the leg and foot muscles. Muscles, like the dermatomes on the surface of your skin, are supplied by different nerve levels. As a rough guide, compression of the upper lumbar segments will cause weakness in your hip and knee muscles. Problems in the lower lumbar nerve roots create weakness in your ankles and toes, while the sacral nerve roots supply the hamstring and calf muscles.

As mentioned earlier, muscular weakness is usually a sign of a severe problem. If you have any apparent muscular weakness associated with your back pain, please see a spinal health practitioner immediately.

###

### Nerve immobility

Nerve immobility is a common and painful consequence of compression. Stuck nerves not only create pain and stiffness in other parts of the hips and legs, but can also exaggerate the original back pain.

Many people are surprised to hear that nerve movement can be restricted, or that nerves need to be regularly moved and stretched. This confusion probably occurs because most people picture nerves as delicate, fine structures that have to be mollycoddled along inside the body. Nothing could be further from the truth. As mentioned in the last chapter, nerves are robust structures, with some being as thick as your finger and as strong as rope.

Your nerves must glide and stretch when you move your legs and trunk - far further than do muscles. This flexibility requirement is so large because nerve cells are very long. They travel vast distances in the body, sometimes even more than a metre, despite the nucleus of the cell being smaller than a pinhead.

To give some further appreciation of the scale of distance, pretend that the head of the nerve is the size of a basketball. In the same scale of measurement, the tail-like neurone would measure a staggering 2.5 kilometres! This long cell length means that a nerve might have to cross many joints on its journey through the limbs. So compared to most muscles, which only cross one or two joints, the movement requirements of nerves are huge.

Luckily, the nerves are well adapted to cope with this movement demand. They have a mechanism in which they slide along inside a tunnel formed by the other bodily tissues. This effect can be likened to a brake cable in a bicycle, in which the central wire slides happily inside its outside casing.

Usually this sliding mechanism works extremely well. However, if a nerve is compressed then its movement will be impeded. To use our previous analogy, suppose that you compress the outside of the brake cable—clamping it with pliers, for example. The inside wire will not slide properly, and any attempt to move it by closing the hand brake lever will simply increase its tension.

Your nerves are the same: compression along their path will greatly inhibit their movement, leading to a rapid escalation of tension when you move your limbs or trunk. The most obvious symptom of neural tension is stiffness. That pulling feeling behind your knees when you bend forward is almost certainly due to immobile nerves, and is not, as many people believe, due to hamstring muscle tightness. Neural tension can also occur in the dura, which causes back stiffness, and can even make it difficult to bend your head forward.

Neural tension can also create problems further along the nerve's path. For example, a back injury can create tension in the sciatic nerve, which can irritate its attachment point on the outside of the knee. If this irritation is repeated enough times, the knee itself can develop pain and tenderness. A whole new injury! This interplay between tension points helps to explain why some people have 'pain everywhere', from headaches and neck pain to a stiff back, and down to aching legs and feet.

The easiest way to think of the nervous system is to consider it as one big, tangled nerve, like a rope with fraying ends, rather than dozens of smaller, independent nerves. Let's look at some cases to help clarify these difficult neural tension concepts. Please remember that these histories are examples only, and by no means exhaustive. Nerve immobility is very complex, and can rear its head in a surprising number of areas:

Gillian, a forty-year-old economics professor, had tenderness and pain around her tailbone, her coccyx. The pain had been worsening for months, and she now had to sit on a doughnut-shaped cushion for relief. When questioned by her spinal health practitioner, Gillian could not recall any trauma; the pain had simply started by itself. During the examination, the spinal health practitioner noticed that Gillian's dura was very immobile, and so checked the rest of her spine. This examination revealed that a bulging thoracic disc was pushing onto the dura, hindering its movement. When combined with Gillian's poor sitting posture, the tension in the dura eventually created pain at its attachment point on the coccyx.

Jock, a twenty-five-year-old elite footballer, felt a rip in the back of his thigh when kicking a football. Assuming he had torn his hamstring muscle, he iced the injury for a few days before strengthening it at the gym. Jock resumed training, and after three weeks of dedicated exercise he rejoined his team in time for the finals. However, twenty minutes into the next game he again felt a tear, and left the field a shattered man. When he sought treatment, the practitioner noticed that Jock's sciatic nerve did not glide properly and elicited pain when stretched. His piriformis muscle was also tight. The diagnosis: Jock's piriformis muscle was hindering the sliding motion of his sciatic nerve, which was why it tore when he kicked the football. It was not a hamstring muscle tear after all.

I hope that you are beginning to see the breadth of complaints that can have nerve immobility as a component. Torn muscles, tendonitis, nonresponsive injuries, fibrositis, even headaches, can be caused by neural tension. Tight nerves not only cause lower back pain, but are a consequence of it as well.

###

### Summary of nerve-related injuries

OK, that just about brings us to the end of nerve-related injuries. Don't worry if you can't remember exact details of each condition. However, I hope that you can see that the usual practice of simply diagnosing any back-related leg pain as 'sciatica' is close to useless.

You should now understand that leg or buttock pain can come from many sources. Referred pain can arise from misinterpreted signals from the nerve's connective tissue, or simply from injured spinal structures. Other strange symptoms or weird pains can occur if the neuron is compressed. A pinched nerve can also develop tenderness and inflammation along its length, as well as becoming tight due to hindered mobility.

When you multiply the many types of referred pain by the variety of spinal injuries, such as disc bulging, stenosis or facet joint sprains, you will appreciate just how complex nerve-related pain can be. Nevertheless, by performing a thorough assessment, a good spinal health practitioner can usually diagnose the source of your nerve-related symptoms.

##  Epilogue to Volume 1: The Causes

Take a bow. Pat yourself on the back. Allow yourself to fill with a hint of satisfied pride. Apart from some bonus material that follows (in which you discover some of my other books that you might enjoy) you have now successfully competed _Volume One: The Causes_.

Believe it or not, you now understand the basics of the anatomy and evolutionary design of the spine, and have a good idea of its component parts. You hopefully have a clear mental picture of the discs, facet joints and nerves, and of the things that can go wrong with them. You have learned a lot, haven't you? Well done.

I now invite you to move along to _Volume 2: The Cures_. In this volume you will perform an important self-assessment quiz that will classify your back pain, so that you will learn how to cure _your_ pain, not someone else's.

You'll then create a personalized exercise program, and glean advice on a whole range of issues from sitting to supplements to scans, and from muscle imbalances to mental aspects to myth busting.

By the time you have completed _Volume 2: The Cures_ , you will have a complete blueprint of how to get rid of your back pain forever. I hope you also have a laugh along the way.

If you haven't yet downloaded an e-book of _Volume 2: The Cures_ , you can find purchase information at www.JPpublishingAUSTRALIA.com or by searching at your favourite e-book retailer.

Enjoy, and good luck!

## More great books from JP Publishing Australia

The Wondrous Adventures of Captain Rum

Historical Fiction/Maritime adventure

Adult/Young adult

Published by JP Publishing Australia

Available as print or E-Book

Campervan Kama Sutra

Travel/comedy

Adult/Young Adult

Published by JP Publishing Australia

Available as print or E-Book

A Few Quiet Beers with God

Science fiction/comedy

Young Adult

Published by JP Publishing Australia

Available as print or E-Book

Using Your Brain to Get Rid of Your Pain

Self help/healthy living

Published by JP Publishing Australia

Print: ISBN 0 9577 4041 7

E-Book: ISBN 978-0-9875694-0-0

Note: Much of the information in this book is also contained in _Volume Two: the Cures_ of _Back Pain: How to Get Rid of It Forever_

Back Pain: How to get rid of it Forever (print edition)

Self help/back pain

Originally published by Hale & Iremonger, Sydney: ISBN 0 86806 675 3

Now published by JP Publishing Australia

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"Captain Rum: A Wondrous Adventure"

Edited by Prof. H.D. (Bert) Lampluck

When an Oxford Professor stumbles upon an old naval Captain's log, he unwittingly discovers what many scholars now agree is one of the greatest maritime adventures in history.

In 1821, Captain Fintan McAdam set sail from London, solo, in search of adventure. During his journey he discovered incredible new worlds, and interacted with their amazing inhabitants. McAdam's voyage also forced him to confront his enemies within, learning much about himself.

_Captain Rum_ , as told in McAdam's own words through his journal, is a tale of discovery, despair and delight. It will keep you enthralled through many a stormy night.

More...

www.JPpublishingAUSTRALIA.com

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"Campervan Kama Sutra"

Around Australia with a camper trailer, three kids and a dog*

This true story tells of one family's hilarious journey through Australia's rugged outback countryside.

Our intrepid adventurers work their way through numerous mishaps, including, but not limited to, an ill-advised river crossing, an inappropriately packed roof rack and some truly horrible singing.

During their journey they stumble across a motley assortment of characters such as a confused check-in clerk, a grey nomad with an eye for detail regarding torches, and several Crazy Germans.

While reading Campervan Kama Sutra, you'll not only fall in love with Australia's vast, ever-changing countryside, but you'll also delight in the tragicomedy that arrives with unerring regularity. You'll laugh until something hurts.

*P.S. There was no dog.

More...

www.JPpublishingAUSTRALIA.com

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"A Few Quiet Beers with God"

Set in Australia in the year 2031, this story is science-fiction comedy at its best.

When Dave, a hopeless but lovable 34 year old, meets Alexandra, the girl of his dreams, he feels as though his luck has finally changed. But due to his ineptness with technology, he tragically loses contact with her.

Meanwhile, the lust for supremacy of two powerful Americans ignites a bitter feud. Their fight reaches around the globe and soon entwines not only Dave and Alexandra, but also a superstar football player nicknamed 'God'.

Their final meeting precipitates an event that no-one saw coming.

More...

www.JPpublishingAUSTRALIA.com

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Connect and Contact

Publishing contacts

E-mail: mailto:JDPpublishingAUSTRALIA@gmail.com (note the extra D)

Publishing website/blog: www.JPpublishingAUSTRALIA.com

### Facebook page (publishing): <https://www.facebook.com/JPpublishingAustralia>

Physiotherapy contacts

Physio Website: www.physioworks.com.au

Physio Blog: <http://mansfieldphysioworks.wordpress.com/>

Facebook page (physio):  https://www.facebook.com/Bulimba.Mansfield.Physioworks

###

### Bulimba PhysioWorks

Shop 3, 175 Riding Rd,

Bulimba, Brisbane

Australia 4171

bulimba@physioworks.com.au

Ph +61 (0)7 3899 1226

###

### Mansfield PhysioWorks

Suite 11, 296 Newnham Rd

Wishart, Brisbane

Australia 4122

mansfield@physioworks.com.au

Ph +61 (0)7 3849 3099

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