Spines Don’t Collapse

Over the years, the spine has been badly served by the tower metaphor.

Generations of people have been told to imagine it as a stack of blocks, one vertebra sitting neatly on top of another, with muscles acting like guy ropes trying to stop the whole thing falling over. The image makes a certain kind of sense. The spine appears vertical, carries weight and has curves, so it seems reasonable to talk about alignment, stacking and possible collapse.

The problem is that bodies aren’t buildings which are constructed and then occupied. A spine is grown, remodelled, moved, loaded and worried about adapted over decades: a biological system in constant conversation with the demands placed on it.

The bony spine aspect is of course hugely important. It protects the spinal cord, gives form to the body, and provides anchorage for muscles, ligaments, fascia and viscera. But vital as it is, it is not the whole story.

Move your neck and the rest of the spine has to respond. Breathe, and the ribs, diaphragm, abdominal wall, pelvic floor and lumbar spine all join in. Coughing, laughing, bracing, lifting, twisting, and even sitting still, all involve changes in spinal behaviour. These behaviours emerge from combinations of muscular adjustments, fascial tensions, pressure changes and complex nervous system decisions.

Most low back pain is classified as non-specific, meaning that a single clear structural cause can’t usually be identified. This never means that the pain is imaginary or unimportant, but that the relationship between systems, is much more complicated than a simple fault-finding model allows (Hartvigsen et al., 2018). (PubMed)

Clients often arrive with familiar well-practised stories about their spine and the potential causes of pain. A bulging disc, a pelvis or SI joint that is “out”. Perhaps a ‘weak core’ or ‘degeneration’, and of course ‘wear and tear.’ These phrases are not neutral, but contain a host of personal interpretations that carry weight. They affect how people move, what they fear, what they avoid, and what they believe their body can tolerate. And importantly they’ve mostly been fed this by someone else.

As well as phrasing, imaging is another reason to be careful. Brinjikji and colleagues found that spinal degenerative findings are common in people without pain, and become more common with age. Disc degeneration, bulges, protrusions and facet changes can all be present in people who are symptom-free (Brinjikji et al., 2015). (PubMed), a story repeated across other joints.

As Robert Schleip once put it, most people with a bulging disc don’t have back pain, and most people with back pain don’t have a bulging disc. A scan is a picture of anatomy at a specific point in time, not a complete explanation of someone’s experience.

What I call the ‘Posture Industry’, has done a remarkable job of making people, especially women, suspicious of their own bodies.

Swiss finishing schools in the 1950s taught young women to balance books on their heads and aspire to “elegant posture”. The message was not simply biomechanical but was social. Posture became a marker of style, class, discipline, attractiveness and self-control.

“A rounded back, sagging shoulders and a drooping chin create an image of extreme lassitude or discouragement with life…and being ten years older than you really are.”

A woman’s posture was being used as, social and aesthetic judgement, with a rounded back implying laziness, discouragement, ageing, and a failure to present oneself ‘properly.’

This kind of depressing and persistent trope, pressurising young women to aspire to impossible standards, still exist today. ‘Sit too much and your spine will collapse’. ‘Look down and your neck will hurt.’ ‘Round your back and your discs will fail’.

There are grains of usefulness around fascia and patterns buried in some of this. A habitual forward head position may become part of a person’s movement pattern and could, in some contexts, contribute to balance or loading issues later in life. But turning posture into a moral failing, beauty standard, or permanent diagnosis is not good science or good care.

The evidence linking specific static postures to low back pain is far less tidy than popular advice suggests. Reviews have found inconsistent evidence and limited support for simple causal claims between particular spinal postures and back pain (Swain et al., 2020). (PubMed) Take that judgy mothers!

The spine is not at all offended by flexion, extension, rotation or side-bending. It is built to move and can tolerate remarkably large loads. The better question is whether the person has the capacity, tolerate and recover from the demands.

Stiffness is often treated as the enemy: something to be released, softened or corrected. That can be useful, but stiffness can also be a strategy. When people have spinal pain, their motor control can change and they may move less or guard the painful area. These changes aren’t simply weakness, but often involve coordination, timing, attention and protection (van Dieën et al., 2019). (jospt.org)

Instead of saying, “This is tight, therefore it must be released,” we might ask, “Why is the system choosing stiffness here?” Manual therapy, movement, education and graded exposure can all be useful, but the ultimate aim is to help the person access options.

Breathing is often erroneously treated as separate from spinal mechanics. The diaphragm attaches to the lower ribs and lumbar spine, changes pressure in the thorax and abdomen and works with the abdominal wall and pelvic floor. General anatomical sources describe the diaphragm as the primary muscle of respiration and note its attachments to the sternum, lower ribs and spine. (Cleveland Clinic)

This isn’t saying that every back problem is “really” a breathing problem. But holding the breath to lift, bracing under threat, or shallow breathing under stress, all change the mechanical and sensory environment of the spine.

The spine also sits in a larger fascial and muscular field. The posterior layer of the thoracolumbar fascia has been studied in relation to load transfer between the spine, pelvis, legs and arms (Vleeming et al., 1995). (PubMed)

I am however wary of just saying “everything is connected”. The skill is deciding which connections matter for this client, under this load, with this history. Everything adapts under load over, including bone (Rosa et al., 2015; Ma et al., 2023). (ScienceDirect)

But curves, thickening, stiffness, altered movement and some degenerative findings may be signs of adaptation rather than simple failure. Remember that a strategy that helped someone survive one period of life may become less useful later, but it doesn’t mean that anything is breaking down.

NICE guidance for low back pain and sciatica advises against routine imaging in non-specialist settings and encourages advice, self-management, normal activity and exercise, with manual therapy considered as part of a broader package rather than as a stand-alone fix (NICE, 2016/2020). (NICE). This is pretty inclusive and consistent with seeing the body as an adaptive system, without creating a villain (or hero) out of one particular tissue or posture.

The spine is not a stack of bricks waiting for gravity to win, but rather a living, adapting system trying to solve problems. Once we understand that, we can stop asking where the fault is and start considering what the system is trying to manage.

References

Brinjikji, W. et al. (2015) ‘Systematic literature review of imaging features of spinal degeneration in asymptomatic populations’,American Journal of Neuroradiology, 36(4), pp. 811–816.

Hartvigsen, J. et al. (2018) ‘What low back pain is and why we need to pay attention’,The Lancet, 391(10137), pp. 2356–2367.

Ma, Q. et al. (2023) ‘Significance of mechanical loading in bone fracture healing, bone regeneration, and vascularization’, Journal/source to verify in Zotero.

NICE (2016, updated 2020)Low back pain and sciatica in over 16s: assessment and management. NICE guideline NG59.

Rosa, N., Simoes, R., Magalhães, F.D. and Marques, A.T. (2015) ‘From mechanical stimulus to bone formation: a review’,Medical Engineering & Physics, 37(8), pp. 719–728.

Swain, C.T.V. et al. (2020) ‘No consensus on causality of spine postures or physical exposure and low back pain: a systematic review of systematic reviews’,Journal of Biomechanics, 102, 109312.

van Dieën, J.H., Reeves, N.P., Kawchuk, G., van Dillen, L.R. and Hodges, P.W. (2019) ‘Motor control changes in low back pain: divergence in presentations and mechanisms’,Journal of Orthopaedic & Sports Physical Therapy, 49(6), pp. 370–379.

Vleeming, A., Pool-Goudzwaard, A.L., Stoeckart, R., van Wingerden, J.P. and Snijders, C.J. (1995) ‘The posterior layer of the thoracolumbar fascia: its function in load transfer from spine to legs’,Spine, 20(7), pp. 753–758.