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Introduction

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There's no doubt that everyone has experienced back pain at some time in his life. The frequency and seriousness of it differ greatly from person to person. Nevertheless, it is easy to trace the source of back complaints. Most of them are caused by mechanical overloading: defective stance, lifting heavy objects, poor physical condition, etc. In addition, there are also psychosomatic back complaints, whose origin can be traced to a person's psychological burden and its influence on the body. It is important when dealing with back complaints to make a distinction here - though both types have an influence on the vertebrae and the experience of the back in general. To that extent, back complaints form a socio-economic problem through absence because of sickness, unavailability for work and long-term invalidity.

 

Still, there are many differences of opinion about the causes of back trouble. Does that pain come from the small inter-vertebral joints, the so-called articular facets, or is it because of defective functioning of a disc, muscles or ligaments? One thing is indisputable: there is pain. Extremely important then are the positions of the body and a good night's rest on an ergonomic bed will contribute greatly to the proper functioning of the back.

 

Yet we can confirm that in the case of mechanical back pain, 80% of complaints can be traced back to the spinal discs. The articular facets and joint ligaments are responsible for the other 20%. In this respect we have to remember that the ligaments themselves are provided with more pain-receptors than the spinal discs and will for this reason lead to back complaints more quickly.

 

It is of course also possible that back pain is the consequence of an illness somewhere else in the body. Thus gynaecological disturbances, kidney complaints or tumours can also be responsible for lower back pain. The explanation must come from the right diagnosis.

How does mechanical back pain start ?

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One of the most important causes of lower back pain is probably the incorrect use of that back. Daily activities such as lifting, dragging and sitting for long periods on a bad chair or lying in the wrong position will be some of the causes of non-specific back pain. Non-specific back pain means back complaints that can often be traced back to and are dependent on the activities of the sufferer - for example, people with a sedentary or standing profession (conveyor-belt workers, secretaries, truck drivers, teachers and instructors).

 

With these complaints it is sometimes difficult to discover precisely where the back pain comes from. One fact is certain: something is wrong with one or more spinal segments. In this respect, pressure on the discs can be an important factor. The Swedish researcher Nachemson has measured the pressure at the level of the third lumbar spinal disc on a number of test subjects. The results were remarkable. In an upright position we say that the pressure is 100%. This pressure increases during sitting and when lifting things. Furthermore, it appeared that there was always a certain amount of intra-discal pressure, regardless of the position.

 

An accident can be a primary cause of back pain. We are not just talking about serious accidents causing major damage. Repeated micro-traumas can also lead to severe back pains. Tripping unexpectedly on a step can be sufficient to cause back pain. Incorrect exercise therapy and fitness training under poor direction can also contribute to back complaints.

Mechanical back pains

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Intro

Back complaints can be traced back to specific affections of the back. Examples of this are Bechterew's disease (its characteristic being the gradual stiffening of the spinal column), osteoporosis (decalcification of the bones, Scheuermann's disease (a growth disturbance in several vertebrae), severe scoliosis (sideways curvature sometimes coupled with rotation of the spinal column).

Yet the aforementioned affections are a minority of the causes of mechanical back pain. In fact, there is not much to see in the medical histories of most back patients, but the seriousness and frequency of the pain are considerable. In medical circles they are referred to as non-specific back complaints and these represent 90% of back problems. Non-specific back complaints are caused by incorrect use of the back. Faulty positions and movements, incorrect lifting of heavy objects - these increase the pressure in the nucleus of the vertebral discs. This in turn causes disc problems.

These affections of the lower back are not only the consequence of wear and tear to the discs. We can subdivide them into two major categories: the primary discogenous affections (PDA) and the secondary discogenous affections (SDA).

 

Primary discogenous affections

Primary discogenous affections arise through mechanical overloading of the ligament ring - generally leading to a tear or distortion to the back of the disc, caused by a sudden or long-term flexion-rotation of the back. The complaints are provoked by activities such as bending forwards, lying down badly and sitting in positions where there is not enough support for the lumbar region. Sitting if often more painful than walking upright. Patients are usually younger than 45 years old and their x-ray photos often show no observable changes.

This flexion-load is coupled with increased pulling on the ligament rings and higher pressure in the nucleus of the vertebral disc. The back of the ligament ring undergoes pulling and the front of the ring undergoes compression with an increase in pressure. The nucleus absorbs this pressure and shifts backwards and presses on the hindmost ligament rings that as a result may become torn. Some of the consequences of this are a disruption of the static stress in the vertebral segment and a change in pressure on the articular facets and ligaments. Because these structures are richly provided with nerves, this can lead to severe local pains.

 

Secondary discogenous affections

The secondary discogenous affections (SDA) are a consequence of earlier injuries (PDA) to the vertebral disc. A tear will cause a scar, which means a weak spot in the future. Repeated injury to the ligament ring disturb the entire function of the vertebral segment: degeneration of the vertebral disc, increased load on the articular facets, arthrosis of the joint surfaces, etc. One provoking factor in secondary discogenous affections (SDA) is bending backwards especially, which differs greatly from PDA. During extension, loading raises the pressure on the articular facets and the consequence of that is joint cartilage pain or facet pain.

It is not always possible to distinguish clearly between primary and secondary discogenous affections. They are extremes and after a time they overlap each other. The consequences of this discogenous suffering are made clear in the back problems described below.

 

Lumbago

Lumbago is a pain that suddenly strikes in the lumbar region. The pain does not spread but remains localised in the lower back. It is almost impossible to stand up straight again. The cause is to be found in an overloading of the spinal column, for example by lifting or sitting badly. It feels as if you have been shot in the back.

Lumbago can be cured quite quickly by resting and relaxing the lumbar muscles. However, there is a considerable risk that it will return. It must be pointed out to the patient that he should do something about the cause of the problem. Research has shown however that 55% of the people who have suffered damage tot he ligament ring run the risk of getting sciatica within 5 years. What might be described as doing the breast-stroke lying face up in the swimming-pool is one good way of avoiding this.

 

Disc protrusion

If stress is repeatedly applied to the ligament rings, the nucleus has the tendency to be displaced backwards and eventually become torn. Only the outer fibres of the ligament ring prevent the nucleus from popping out completely. This is called disc protrusion in the medical literature.

The result of protrusion is that the nerve roots and joint ligaments become irritated. The inter-vertebral disc moves backwards and presses on these tissues. Pains arise from this continual pressure, though the pain is not just limited locally, but can also spread to the buttock region or down to the legs.

 

Hernia

If the outer fibres of the ligament ring also tear, the softer nucleus bulges out. Then we talk of hernia or a prolapse of the disc. A lumbar hernia occurs in 50% of cases at the level of L5-S1 and in 40% of cases at the level of L4-L5. The bulging mass goes on to press on the surrounding tissues. If this happens to ligaments, periosteum, inter-vertebral joints or nerve linings (dura mater), we speak of pseudo-radicular pain. Often these are patients who complain in the morning of stiffness and pain, the complaints decrease as the day progresses.

 

Radicular pain is typical of the pressure caused by the hernia on a nerve root. The pressure can not only cause inflammation locally, but also influence the course of the nerve root. The pain is characterised by its acute and specific places. There is often more pain in the leg than in the back. The pain gets worse when coughing, sneezing and pushing, and will be more intense when sitting than standing.

 

Sciatica

Sciatica, or a crushed nerve, is caused by pressure from the hernia on a nerve root. It is a radicular pain that causes an inflammation in that area with intense, spreading pain in the back, the buttocks, sometimes even the whole leg as far as the foot. Through the specific localisation of the pain it is possible to check at what level in the spinal column there is an injury. The pain progresses through the nerve branches of the ischium (posterior crural nerve), the great nerve to the leg.

One of the consequences of Sciatica can be that the muscle-power of the leg is reduced and that there is a disturbance to sensation in the leg.

 

Facet pain and degeneration of the inter-vertebral disc

The elasticity of the disc is reduced by repeated injury and ageing of the inter-vertebral disc. Less moisture is absorbed and the distance between is reduced. This can be clearly seen in x-ray photographs. Wear and tear of this kind will occur most quickly in the inter-vertebral spaces which are subject to the most stress. It is understandable that the lumbar vertebrae are more sensitive to this. The nerve roots can come under pressure, with spreading pains as a result.

 

As a consequence of this degeneration of the intervertebral disc, the rearmost articular facets also become subject to greater loading. Pain can occur when pressure on the joint structures is increased: known as facet pain or joint cartilage pain. These complaints tend to appear more in older people. Extension positions of the back should be avoided.

 

Arthrosis

In the course of time the bone-accretion on the joint surfaces will occur through ageing: calcification and osteophytic growths. This is a degeneration of the joints and is irreversible. The only help in these cases is supportive therapy and follow-up treatment.

 

Clearly, an arthrosis patient would be greatly helped with an ergonomic lying position to reduce the pressure on the joint surfaces. An electronically adjustable slatted bed-base is a real relief for such people. The bed is furthermore often used for resting, in various positions with good back support.

Psychosomatic back pains

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Back pains occur not only through mechanical over-loading. Stress or depression can have an influence on the musculature and cause hypertonia. Side-effects in this case are migraine, back and neck complaints, stomach pains, hyperventilation, etc.

 

Because of the continual chronic hypertonia, the back muscles cannot relax any more and will continue to cause pain for a long time. There is therefore a suitable therapy for psychosomatic back pain: relaxation therapy, possibly supported by muscle-relaxing medicines and tranquillisers. Important in the approach to psychosomatic back pain is the relaxation and rest that can possibly be found in a pleasant and comfortable bed. The bed can also be used for resting during the day.

 

For people suffering from depression, a 'warm' and 'inviting' bedroom is recommended for the process of repair. One characteristic of depression is sleeplessness. So it is advisable that the bedroom be made as pleasant as possible, freed from previous emotions and problems.

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Bedrest remains the most important item in the treatment of back complaints. Despite all possible therapies, it is essential that a back pain patient takes care of his rest. Moreover it should obey the fysiological curves of the body. A good rest reduces the pressure on the intervertebral discs and surrounding ligaments. Muscle tension decreases proportional to the duration of bed rest. Anyhow with respect for the above mentioned conditions for a good sleepsystem.

 

In case of acute back pains, it may be appropriate to rest in bed during the day. In this case a minimal of 4 hours should be a minimum. The position can be adjusted to the condition of the back, this in consultation with the treating physician or physiotherapist/physical therapist.

 

Hierbij vertrekken we steeds vanuit zijlig, trekken de knieën op, strekken de benen over de rand van het bed en drukken gelijktijdig de romp opwaarts door op de armen te steunen. Zo bekomen we een zithouding op de rand van het bed.

 

Stepping in and out of the bed is done in such a way that the lower back is moving. This always starts from a lateral position, the knees are pulled up, the legs stretched over the edge of the bed and supported by the arms the hull is pushed up. The result is a sitting position on the edge of the bed.

 

Het kan voor rugpatiënten erg nuttig zijn, zich een hoog bed aan te schaffen. Bedden van 55 à 60 cm. zijn eenvoudiger om vanuit zit recht te komen. Tevens zal het bedopmaken eenvoudiger zijn.

 

 

Avoid twisting movements in the back. A very bad way of standing up is : pushing up the hull thanks to stretched legs. Back patients could be interested to purchase a high bed : in high beds 55 to 60 cm it is easier to get straight up from lying position. Refreshing the bed is also easier.

What is sleep ?

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The way we lie down has an influence on reducing mechanical back complaints. The stresses exerted throughout the day on the spinal column tire the back muscles. For this reason, a relaxing night's rest is hugely important for physical as well as psychological recuperation.

 

Sleeping is not so obvious for everyone. For many people, sleeping is very simple. They go in a restful mood to their bedrooms and are already enjoying a pleasant night's rest. After a few minutes they fall into a deep sleep and then it's only the alarm clock that wakes them in the morning. Refreshed and in good humour, they leap out of bed and take great pleasure in going about their daily tasks.

 

Unfortunately, this scenario does not apply to everyone and sleeping is not such a pleasant experience for them. For many of us, it is a real effort to get enough hours of uninterrupted sleep. Both acute and chronic back pains can disturb falling asleep and staying asleep. For some people, sleeplessness is a torture in which they spend the night, which should bring rest and peace, tossing and turning in bed and just cannot get to sleep. After a lot of worrying and, in the knowledge that the following day is going to be lousy because they didn't get enough sleep, they finally fall asleep towards morning and when they do get up, it is only a short time before they feel too tired to be able to function properly.

What is healthy sleep ?

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We won't dwell on this, since we go to sleep in the evening and wake up again about 8 hours later. It is like a large passive period in which we do nothing. On average, we sleep away about a third of our lives. As children we sleep several hours a day longer and as we grow older, this gradually gets less.

 

Sleeping is actually something like eating and drinking, or relaxing and tensing, or like sexuality. It is also a bodily requirement which we in fact do not have to think about. After all, we don't ask ourselves "are we hungry or not?". We really don't have to think about the feeling "are we tired now or not?". Tiredness comes along and we can deal with it by sleeping or not.

The phases of sleep

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Over the last forty years or so much research has gone into sleep and sleep-disturbance. Sleep is not just an unvarying situation of being unconscious. There are different phases we go through during the night. By using an EEG (electroencephalogram), the electrical activities of the brain can be measured. These activities change continuously during the night. We know from this research that sleep goes in cycles.

 

During a normal night's rest of eight hours we go through some five of these cycles. In addition, each cycle is further subdivided into four stages, the phases of sleep which get steadily deeper. These phases are a part of the Non-REM Sleep. Between two cycles we fall into a completely different type of sleep: REM Sleep - Rapid Eye Movements - so-called after a characteristic of this type of sleep: rapid eye movements.

 

Non-REM-sleep

When we relax in bed waiting until we fall asleep, we go from a completely wakeful situation to sleep phase 1. This transition phase lasts about half a minute to 7 minutes. Our minds wander from one thought to another, we can hardly keep our eyes open and then, without being aware of it, we sink deeper into sleep. Sometimes we feel a sort of shock during this phase - a pulling of the muscles - which is purely and simply a sign that we are relaxing and getting ready to sleep. In this phase we wake quickly and we would obstinately maintain that we had not gone to sleep.

 

Phase 2 is the first real sleep, in which there are still fragments of thoughts and where a sound of average volume will wake us up. After a short time we sink deeper in phases 3 and 4, and then we are completely relaxed. We only wake up it there's a very loud noise. Phase 4 is the deepest sleep and if we are woken in this phase, we often don't know where we are. These four phases are called Non-REM Sleep. The body comes to rest, the heart beats more slowly, the breathing is regular and we hardly move at all.

 

REM-sleep

Strangely enough, we don't stay in this deep sleep until morning. But we go back from phase 4 to phase 1 and begin at the first REM Sleep. This sleep is a phase in which rapid eye-movements appear. A group of large cells in the cerebral cortex are responsible for this REM Sleep. The cerebral cortex is the oldest and most primary part of our nervous system. For a short period, the cells send impulses to the brain.

 

Normally, only our senses send signals to our brains to react to the environment in which the body is located. But the brain makes no distinction between information coming from the cerebral cortex or from the senses. As a result, all sorts of things happen in our bodies: breathing and heart rate become faster and more irregular, blood pressure rises and we toss and turn in our beds. This is also the time when we dream and it is assumed that these dreams are basically a big clean-out of our psychological and emotional lives.

 

After this REM Sleep there follows a second cycle and we sink back into the deep sleep of phase 4, after which we come back to the surface with a dream phase during REM Sleep. Each night, we go through an average of four to six cycles like this.

The sleeping pattern outlined above is that of a 'normal' young adult. So we know that there is no such thing as a normal or average person and there are many questions about sleeping and sleep-disturbances.

 

Why we go to sleep and the exact mechanism for doing it is still a puzzle. Even the fact that we wake up after a period of time is a process that is still not understood. Thus a mother can sleep peacefully on a busy motorway, but will immediately be awakened by the slightest murmur from her baby. And it is also remarkable how some people always wake up at the same time in the mornings without needing an alarm clock. Nor is there only one sleeping pattern which every person has to follow.

 

Fortunately, there is such a thing as an individual sleeping pattern, just as every person is unique.

How many hours should we sleep ?

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Everyone has his own sleeping requirement. Trying to sleep less is just like wearing shoes that are one size too small. You might be able to, but it is far from comfortable. It's a well-known saying that everyone needs eight hours' sleep. However, our need for sleep depends more on the quality or efficiency of our sleep. Thus long-sleepers will have longer sleep cycles than short-sleepers and the sleep of these latter will be more concentrated.

 

Age

The quantity of sleep also depends on our age. Thus a new-born baby will sleep about 17 or 18 hours a day and this reduces quickly in infancy to 10 or 12 hours. During puberty the quantity of sleep reduces to 9 or 10 hours. Although the average teenager will try to convince you that he needs 12 hours' sleep and for this reason can't get out of bed in the morning. A young adult will have sufficient with 6 to 9 hours' sleep and an older person will require even less. Thus older people will have less REM Sleep and there is almost nothing of phase 4 and they will awaken more often.

 

Personal

Besides the fact that time spent sleeping and age are linked together, the number of hours spent in sleep differs with each person. There are people for whom 4 hours' sleep is quite sufficient and others who need more than 10 hours. In Figure 18 you can see the number of hours' sleep we need. Most people, 40%, sleep for about 8 hours.

 

Situation

We cannot compare our need for sleep with someone else's. Anyone who is in good condition will need less sleep. So when we are very busy we will also need less sleep than when we are not. We also know that we sleep more in the Winter than in the Summer, because sunlight and its energy has a stimulating influence on our organism.

 

One of the things you have to check for yourself is your own need for sleep. Are you a short or long-sleeper, are you an early bird or a night-owl? Our sleeping patterns are highly individual and depend to a large extent on our own requirements and wishes. Thus energetic and active people will always be raring to go in the morning, to be sure not to arrive too late. On the other hand, those who often arrive late for appointments sometimes have the feeling that the day is always too short and for this reason they will sleep in later in order to stretch the day out.

 

Of course, this hypothesis will not apply to everyone, though it is possible to suppose that there is a clear link between someone's character and his pattern of sleep. That's why a sleeping-pattern is always an individual matter.

A personal sleepsystem

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Sleep is a personal experience. Objective and subjective factors have an important influence. Finishing, aesthetics and comfort, they all have to meet the personal demands of the sleeper. It is important that the sleeper accept his bed as the best alternative 'him'.

 

Besides this, there are some basic rules, general and not individual bounded, which are valid in the choice of a personal sleepsystem. Three important parameters : conformity, regulation of body temperature and regulation of humidity and sweat. Regarding the position of the body and back complaints we have a closer look into conformity. 

Conformity

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General

A sleeping system with good conformity indicates that the bed is adapted to all body shapes, so that the normal physiological structure of the body is respected. For this we must take the structure of the body into account. There are different variations of level in the outline of a body.

 

Viewed from the side, the spinal column shows differing curves. From top to bottom we can see that there is a cervical lordosis (anterior curvature of the spine), thoracic kyphosis (backward curvature of the spine), lumbar lordosis and a curvature at the level of the knee hollow. In addition, there is the normal sacral curvature which ensures that the posterior sticks out backwards when sitting. A well-supporting bed ensures that when lying on one's back the hollows are supported and allows space for the thoracic vertebrae and the pelvis. Thus we respect the normal physiological curvature of the spinal column.

 

Looking from the front we also see different variations in level. When we are sleeping on our side, the spinal column must be in a horizontal line. It is desirable here that the shoulders and hips get enough room and that the head, loins and legs are supported. Thus a sleeping system with good conformity will have to support the spinal column in its totality.

 

A system too soft and poor conformity

If the under-layer is too soft, the body will sag and then we speak of a 'hammock-effect'. Abnormal curvatures occur, which cause compression on the hollow (concave) side of the spinal column to the soft tissues and joint surfaces. On the convex side of the spinal column there will be a continuous stretching of ligaments and muscles.

That stretching causes pain in the muscles.

 

With acute back complaints we tense the muscles spontaneously and subconsciously to protect the body against unexpected movements. Under-layers that are too soft, sagging or which move about too much do not give enough support to the body. Sleep will be interrupted because pain will occur.

This position causes a 'pothole' effect which will disturb the normal movement of the body during the night. Because of this pothole effect, it is more difficult to change position. So more muscle-power is needed in order to move, so that we are less relaxed and in so doing the quality of our sleep is reduced.

 

A system too firm and poor conformity

If the under-layer is too hard, the spinal column will be supported wrongly. When lying on our side, the shoulders will absorb the pressure - and, to a lesser extent, the pelvis. This causes the spinal column to bend into an unnatural S-shape. This happens because our shoulders are wider than our pelvis. The pelvic vertebrae bend through the influence of nightly relaxation on the one hand and gravity on the other.

 

In addition, an under-layer which is too hard will increase pressure at the points of contact. This has a deleterious effect on the blood circulation of the local tissues. This ischaemia (local blood restriction) stimulates the central nervous system to change position so that the blood circulation can function normally once more. The pain resulting from that ischaemia is reduced in this manner and we can go back to sleep again. But this situation repeats itself later, so that we are awakened at regular intervals.

The comfort of the bed

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A comfortable position is important to get a good night's rest. In this respect the hardness of the mattress and the size of the bed have an important role to play. The degree of restfulness is determined by this comfort.

 

When we are asleep we regularly change position, so that at any given time during our night's rest, the bed must be able to adapt to the body of the sleeper, without disturbing him.

 

In this regard, the bed's dimensions also play a role. An optimal bed-length would be between 20 and 30 cm more than the body-length. There must be sufficient room to stretch out in bed, remembering the space that the pillows will also need. The width too is important. This depends on the length of the legs and width of the shoulders. People with long legs need sufficient room to tuck up their legs when lying on their side. Moreover, restless sleepers will also need more space. A good width would be about 90 cm.

The combination of mattress and mattress support

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As a basic principle we might say that a sleeping system must ensure that the back-patient can get up in the morning without pain and feel good during the day. It is important that the bed feels pleasant and cosy. Sleeping is still a natural need however, one which ensures that we recover from our physical and psychological efforts made during the day. A bed that feels nice is better to lie on and will increase the quality of sleep: subjective influence is very important here.

 

In this respect we must take account of the functional unit that is the sleeping system as a whole and each separate part of it.

 

The mattress

The mattress must be elastic and must distribute the body-pressure over as large an area as possible, so that there are no muscular tensions and disturbances to the blood circulation system. In addition, it must also be firm enough to support the body when at rest. There should not be any hollows in it caused through age and wear.

In this regard it must regulate the distribution of heat and allow humidity to evaporate as much as possible.

 

The mattress support

The mattress support must take the pressure on the mattress in the right way. The base serves to support the body, promote humidity regulation and be durable.

The base must not only absorb the increased pressure of the shoulder and pelvic areas, but will also have to provide support to the other parts of the body. The natural physiological curves of the spine must be respected!

Each point of support the body receives from the base can be seen as a plus-point.

 

The combination

The mattress support must live in symbiosis with the mattress. The quality of a good mattress is largely lost if the base is not suitable. From another standpoint, a mattress which is too hard, for example, can reduce the favourable effect of the base drastically.

The ideal bed provides just the right support for the spinal column in different body positions. I must also be individual, in other words: suited to the physical constitution of the user. Mattresses and bases with fixed zones cannot therefore be used universally.

 

A good bed must support the body completely and evenly, so that we are not obliged to remain lying in one particular position. The degree of conformity determines the value of a sleeping system. People with hyperlordosis (pronounced forward curvature of the spine - "hollow back"), and thus increased dorsal kyphosis, have everything to gain here. Specific back complaints such as scoliosis (lateral spinal curvature) need to have this adaptability. From a preventive standpoint too, care must be taken to ensure that the combination between mattress and mattress support is at an optimum.

Prevention is better than cure.

The pillow

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The pillow is part of the sleeping system. It serves to support the neck vertebrae. The shoulder and neck areas are very sensitive parts of the body and often cause muscle tension and disc pain. The consequences of this are headache, tingling in the hands or a feeling of stiffness in the neck area. Neck complaints often get worse during the night. This is caused by the fact that the pillow does not conform with the constitution of the spinal column at this point.