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Back pain

Through our lifestyle (sitting behind the computer, in the car, watching tv and stress) we spend many hours in a wrong body posture.

We keep our back in the wrong position what causes an excessive tension of the back muscles which try to correct our bad posture resulting in 85% of back problems and pain.
Where does the back pain come from?

Back pain is caused by too much tension on the muscles around the back. The beginning of a vicious circle – back and body can’t relax any more.

Where does the back pain come from?

Back pain is caused by too much tension on the muscles around the back. The beginning of a vicious circle – back and body can’t relax any more.

What causes this 'circle'?

What causes this ‘circle’?

  • poor posture
  • little movement in the thoracic section of the spine (see 1)
  • too much burden on the lower back
  • difficulty to relax

Remarks illustrations

Incorrect sitting stiffens the thoracic spine (thoracic area).
This area of the spine should normally be able to stretch by 5 degrees. This scope is essential for upright sitting and standing. When this section stiffens, this happens in a flexed position, the cervical spine and lumbar spine must correct this by means of a hyperlordosis. The hyperlordosis sets the joints in this area of the spine in a final position. In this position the joints wear out.

In addition, the neck and lower back muscles are constantly tightened to maintain this position.

Constant muscle tension causes muscle cramps and finally degeneration of the muscles. In the end this bad posture will result in much more complaints in neck and shoulder muscles, think of the thoracic outlet syndrome. Even tension headaches and “vague” (back)problems are caused by a wrong posture.

Low back pain

Low back pain

Beside shoulder- and neck pain, low back pain is the most frequent complaint of our physical device. It is estimated that at least 10% of the population of the industrialized countries have problems with his / her back. Yearly 35 out of 1000 patients visit a doctor because of back pain. Only a minority of these patients (less than 10%) require surgery. In more than 90% of the cases no specific disorder can be found. This is called non-specific back pain. Basically anyone can get non-specific back pain and studies have shown that most of the people already suffer from back problems before their 30th. Often it’s a matter of a single episode but for some people the complaints will occur again after a short time.

Reason symptoms keep returning

  • Poor posture and/or movement
  • Muscle weakness
  • Stiffness of the spine
  • Overweight
  • Muscle shortening
  • Limited hip function
  • Leg length difference
  • Pelvic instability

Risk factors are:

  • Frequent lifting heavy and turning movements (especially with straight knees)
  • Muscle weakness and poor general condition
  • Physically heavy work
  • Constantly working in the same position
  • Repetitive work
  • Lifting and sudden extreme effort
  • Subject to constant vibration
  • Depression
  • Smoking

Treatment of back pain

Low back pain occurs all over the world, 80% of the population has low back pain at one time or another (Nachemo 1990). There is done a lot of research on the prevention of low back pain and its treatment. The so-called “Report of the Quebec Task Force on Spinal Disorders” (1987) shows that 74% of people with acute low back pain return to work within 4 weeks and that after 7 weeks only 17% still is suffering pain. All standards in the world are based on this study and you will experience that no doctor will immediately send you to specialist.
Natural course of back pain: percentage of sick leave in relation to the period of pain (based on the Quebec Task Force on Chronic Back pain, 1987).

The above chart shows that the main bend is at 4 weeks and later at 7 weeks.

We can also divide the treatment of low back pain in stages.

Stage 1

Primary therapeutic stage

Less than 4 weeks back pain: we see a positive course in this period, 74% of the people can fortunately return to work. Scientifically there is no treatment that can shorten this period. Yet this does not mean that no treatment is necessary. Physiotherapy can help a lot in this period in the form of advice on how to improve your posture and how to relieve your back. In addition massage, electrotherapy of heat will help to relieve the pain.

Stage 2

Secondary therapeutic stage

Between 4 to 7 weeks back pain. This is the critical phase in the treatment of low back pain. We see in the chart that the course is less favourable in this period. Without any action we see a threatening dysfunction and it’s clear that support in activities is necessary. Studies have shown that treatment in this stage is completely different from that in the first stage. Important in this stage is functional training as well as building up strength, coordination and stabilization and aside boosting the condition. Studies have shown that there is a positive relationship between condition and low back pain.

Stage 3

Between 7 and 12 weeks back pain. We can see an increasing dysfunction and the percentage of people that recover in this period is very small. Also in this period the focus of treatment lies on the support of activities and functional training.

Stage 4

Between 12 and 26 weeks back pain. We clearly see that the cure rate barely increases. It’s becoming more difficult to raise the muscle strength etc via exercises. More functional skills is the only solution.

Stage 5

More than 26 weeks back pain. We see no more shifts. Treatment in special back schools is an option for some extra skills.

In summary

We see that especially in stage 2 it is important to start physical therapy and that as well the information on the kind of back pain and its development and the explanation of postures and movements are important.

Explanation of the factors involved in low back pain

Some knowledge about anatomy and the forces that have impact on your back.

The Back- and Rolastretcher are an alternative method of treatment that has proven very successful. It offers great potential to recover from the following complaints: repetitive stress injury, pain in your low back, stiff neck, tension headaches, radiation to the shoulders, stiff thoracic (chest) spine and excessive lordosis. A better posture is the beginning of rehabilitation. The Backstretcher offers you the chance to correct the alignment of your back. The principle is based on Shiatsu massage. Shiatsu Netherlands supports the use of the BackStretcher and Rolastretchers.


If we look at the spine from the side we see that there are natural curves. The curve to the front we call lordosis, the curve to the back we call kyphosis.
From top to bottom we see a cervical lordosis, a thoracic kyphosis and a lumbar lordosis.

When these curves are too large we speak of posture abnormalities. People with weak abdominal muscles do often have an enhanced lumbar lordosis (extreme hollow back).

The intervertebral discs between the vertebrae often play an important role in the development of back pain. Especially the last two discs are often overburdened.

Motion segment

To better understand the function of the spine, we take as an example a motion segment. Under a motion segment, we mean two vertebrae that are connected via the spinal joints or facet joints. Between the vertebrae is the vertebral disc and on the side we have the nerves which come from the spinal cord. The facet joints form the connection between the vertebrae and allow the vertebrae to move. Just like other joints in the body these are susceptible to arthritis and osteoarthritis. The nerves between the vertebrae in the lower back send the information from the legs to the brains. Pain in the leg can be caused by irritation of the nerves.

The unstable back

It is not entirely clear where the pain in the lower back comes from. It’s not only the intervertebral disc that plays a role but also the facet joints or intervertebral joints together with the irritation of the nerve. The left image shows a motion unit where the intervertebral disc is narrowed and there is an irritation of the spinal joints. The nerve gets squeezed and it depends on the pressure on the nerve and the movements in this segment in how far you experience pain. Changes in the movement unit can also cause shifting of the vertebrae. This leads to an instability which can irritate the nerve. Depending on the strength of this irritation we feel the pain either alone in the back or also radiate to both legs. The radiation seldom goes below the knees.

One consequence of this instability may be that the muscles in the back cramp to fix the back in this way as a protection. Prolonged spasm of the back muscles results in back pain too. The back feels hard, is stiff and provokes a wrong posture in order to avoid the pain.

At the moment that the nerve gets irritated at one side, we can see the radiation to the left or right leg. Pain can now even radiate to beyond the knee and studies show that the pain increases when the nerves are stretched. We often call the irritation of the nerve sciatica which is the name of the hindleg nerve.

In summary we see that the following structures play a role when there is an irritation within the motion unit:

  1. The intervertebral disc
  2. The intervertebral joints
  3. The nerve that gets stimulated in the intervertebral space

In case of complaints coming from the intervertebral disc we often see that the pain increases when we are sitting too long or bent over because in this postures the pressure on the intervertebral disc is directed more to the back where the nerves run. Constantly standing with a hollow back will irritate more the intervertebral joints. Especially in cases of arthritis (inflammation of the joints) or osteoarthritis (aging of the articular cartilage) we see that standing and walking for long time increases the pain.

Damages intervertebral disc

Many problems of the spine are resulting from degeneration of the intervertebral disc. Different postures and movements can cause changing pressure on the intervertebral disc. Especially movements with a bold back have a bulging effect on the intervertebral disc to the back. In the figure we see that the pressure on the intervertebral disc can vary from 25 to 275 kg depending on different postures. If back pain is caused by an irritated intervertebral disc, it can clearly be stated that lying down will relief the pain and constantly sitting in a low soft chair (think of the car seat) will cause most complaints. Forward bending postures (think of working at a low kitchen unit) will cause a high pressure on the intervertebral disc which is directed backwards.
On the photo: intradiscal pressure on the third lumbar intervertebral disc in the following postures (left to right): supine position, lateral position, standing, standing 20 degrees bent over, same with a weight of 20 kg, sitting without support, sitting 20 degrees bent over and the same with a weight of 20 kg. (according to Nachemson)

The nightmare, the often discussed Hernia

The following story shows how the changes in the intervertebral disc can lead to a hernia. It is obvious that this is a final stage and the complaints belong to specific back pains. After a simple examination your physiotherapist can easily tell you if he is thinking of a hernia and will suggest a follow-up treatment. (Besides, 80% of hernias cure spontaneously.)

The first changes in the intervertebral disc due to overburden are little cracks in the layers around the nucleus. When these cracks heal scar tissue will be developed. Scar tissue however is not as strong as the original tissue. Repeated overburden will finally result in degeneration of the intervertebral disc. The shock absorption will decrease; the intervertebral disc will become thinner because loss of moisture from the nucleus. The cracks in the layers can become so big that the nucleus will lie against the roots of the nerve. This pressure on the roots will cause a radiating pain on the run of the nerve together with numbness and muscle weakness.

We speak of a hernia nucleus pulposus which is the Latin name for bulging intervertebral disc.

On the pictures left and right you see some evident examples of hernias. In practice we do not encounter too often such evident examples. However, even a slight pressure on the intervertebral disc can lead to severe pain. At the moment that failure symptoms occur it is necessary to contact the doctor as soon as possible. Paralysis of leg muscles (not be able to walk on heels or toes) or failure of bladder function and of the sphincter are the most common symptoms. The protrusion of the hernia is so great that the nerves are completely squeezed.
Read more news about a hernia at the site of

Posture while working

From above story we learn that constantly sitting is too much burden for people suffering from back pain. That’s why a well equipped working place is essential for the treatment of low back pain. On the site VDU you’ll find more information.

General considerations when bending and lifting:

  • Lift quietly
  • Lift heavy things as close to the body as possible
  • Do not lift above shoulder height
  • Avoid bending forward too much
  • Avoid turning and bending sideways
  • Lift with both hands

Picking up objects
Only pick up objects when you can hold on to something fixed to support you. Bend through your knees with a straight back.

Obesity, an important factor
It is a fact that 10 kg overweight will increase the pressure on the intervertebral discs by 40 kg. Physiotherapists use scales which measure beside weights also the fat percentage. Another way is to calculate the Body Mass Index which is based on the relationship between heights and weight. For the treatment of low back pain it is more important to measure the fat percentage than to determine the body mass index.

Physiotherapy and low back pain (directive KNGF)
he physiotherapist differentiates between specific and non-specific low back pain. In case of non-specific low back pain there is no specific physical cause for the pain such as a squeezed nerve or an inflammation.

But in 90% of all cases there is no specific cause for the pain. 60% of all people spontaneously suffer from back pain because of a wrong movement (bending or lifting). In 40% the pain gradually increases without apparent cause. Besides stiffness of the back, especially the so called morning stiffness, pain is the main complaint.The natural course of the symptoms is favourable. In 80-90% of the cases the symptoms disappear within 4-6 weeks. For this group physiotherapy is limited to provide information and to give advice for adapted activity.

A different case arises if the complaints after 3 weeks have not diminished but even increased. People then need more rest during the day, take more medicine and are less active. At this stage of the course the physiotherapist will ask when the symptoms started and what you are able to do or not. Sometimes they use questionnaires such as the Quebec Back Pain Disability Scale. The Patient Specific Complaints List (Beurskens) is also used as instrument for determining the severity of your symptoms.

Physiotherapists made a classification of low back pain based on the duration of the pain: acute (0-6 weeks), subacute (7-12 weeks) and chronic (more than 12 weeks). Compared to the classification in stages we see that stage 1 corresponds to the acute period and stage 2 and 3 with the subacute period. The chronic period covers the other stages as described in the beginning of this brochure.

According to scientific literature bed rest is not useful as far as acute back pain is concerned. If bed rest really is necessary it’s advised to keep it short (up to two days). The best remedy for acute and subacute low back pain is staying active. In case of chronic back pain exercises will be effective. Exercises in water point out to be effective for patients with chronis back pain.