Importance and incidence of locomotor system dysfunctions 363
8.2 Principles and goals of prevention 364
8.4 Manipulation as a prophylactic measure 369
8.1. Importance and incidence of locomotor system dysfunctions
The previous chapter in particular has highlighted the role of dysfunctions of the spinal column in the pathogenesis of pain involving the locomotor system. That discussion will enable us now to formulate a strategy for their prevention as we remind ourselves that it is possible to apply preventive principles not only to therapy itself, but also to rehabilitation, the main goal of which is to ward off relapses and complications.
Before going into detail, we first need to consider the importance of locomotor system dysfunctions and the sheer scale of the problems they pose. The patients we see comprise the vast majority of all those who suffer from back pain and from pain associated in any way with the spinal column. The statistical data are unreliable because our patients are recorded under a range of different diagnostic labels, for example headache, chest pain, vertigo, rheumatism, etc. Many patients who suffer constantly from these painful conditions do not even seek medical help, having learned from experience that conventional treatment is ineffective: and so they escape the record. Even so, the statistics are impressive.
The category heading of ‘soft-tissue rheumatism’ clearly includes many patients suffering from locomotor system dysfunctions. As a cause of absenteeism from work, it is a sobering fact that locomotor system disorders rank second only behind common infections of the upper respiratory tract. However, if we consider only those locomotor system disorders that are of vertebrogenic origin, we find that they account for 15 million lost working days.
Table 8.1 gives official data from the Czech Republic. These give a good overview and are significant economically; they cover only patients who missed work because of their symptoms.
|*Since 1989 ‘vertebrogenic disease’ has no longer been categorized separately in the statistics issued by the Ministry of Health of the Czech Republic.
|Disease category||Year||Average number of working days lost|
|Locomotor system disease||7898||9451||11798||11627||21.9||53.0|
Impressive though this statistic may be, unfitness for work is only part of the problem. It is mainly low-back pain and/or pain in the lower extremities that renders people unfit for work, and ‘unfitness’ also depends on the nature of the work involved. It is therefore critical to cite data that relate more directly to the incidence of locomotor system dysfunctions. According to Säker (1957), in a survey population aged between 60 and 80 years, 440 out of 1000 people questioned stated that they had experienced at least one episode of low-back pain or sciatica in their lives. In his 1951 study conducted in Stockholm among 1200 workers from a variety of occupations, Hult (1954) found current symptoms or a history of cervical disk or lumbar disk lesions in 51% and 60% respectively. In a randomly selected rural district near Prague, Uttl (1966) found that 61 subjects from a representative sample of 100 had a history of vertebrogenic symptoms.
When older and more recent data are compared, it is evident that the incidence of such dysfunctions is increasing year on year and that the number of lost working days has in fact doubled over the course of 20 years. Locomotor system dysfunctions primarily affect middle-aged individuals, that is those in the most productive years of their working lives. Treatment is frequently time-consuming and costly, and there is a marked tendency for these conditions to become chronic. The cardinal symptom is pain, and this is associated with a burden of suffering that is impossible to quantify. According to Frymoyer (1991, Frymoyer et al 1980), back pain affects 80% of the general population at some point in their lifetime.
8.2. Principles and goals of prevention
As locomotor system dysfunctions play a key role in the pathogenesis of back pain, it is important to know the circumstances that most frequently produce them. Major factors here also include muscle imbalance, instability, and faulty patterns of muscle movement, among which incorrect breathing is probably the most common.
No less important is the influence of the modern industrialized world in which we live: not only have our dietary habits altered, but we are also exposed to air and water pollution and to risks from chemicals and radiation. And the change in our locomotor habits has been no less radical: although we have become increasingly sedentary, excessive static strain is on the increase. It is precisely this that produces the imbalances described by Janda: our predominantly postural, phylogenetically ‘older’ muscles become hyperactive and contract, whereas our predominantly phasic, phylogenetically ‘younger’ muscles grow flaccid. The same process is also at work in the deep stabilizers. This is one reason for the epidemic increase in disorders involving the locomotor system and spinal column.
Instead of walking, or even riding, we sit or stand in automobiles and other vehicles in which we are jolted about. Most work nowadays is carried out in a more or less fixed position, frequently sitting or bending forward. Long hours of working at the computer are especially harmful. And the worst thing about this unfavorable trend is that it begins in early childhood: in front of the TV screen, sitting in school, or playing computer games. Children travel to school by automobile, bus, or tramcar, even though the distance may be short. Healthy children may resist this trend for a while, boisterously involving themselves in fun and games, but once they start to grow older they are seduced by the appeal of watching TV, riding motorbikes or sitting in a café or bar. These facts deserve to be emphasized because the public gaze is so narrowly focused on environmental pollution that the harm done as a result of changes to our patterns of locomotor behavior is easily overlooked. From this there emerge two logical approaches to prevention: one is to minimize excessive static strain as far as possible, and the other is to seek to compensate for it by exercise.
Our highly-developed technological society is suffering from the twin evils of sedentary lifestyle and excessive static strain.
8.3. Lifestyle factors
8.3.1. Passive prevention
As most of our time is spent seated, a correct sitting position is of great importance. This, however, depends on the chair used: the height of the chair is correct if the subject’s thighs are horizontal, with feet resting flat on the floor. The back of the chair should provide support where the kyphosis peaks in a position of complete relaxation (see Figure 6.159). When the patient is sitting relaxed, the peak of kyphosis is more often in the lumbar than in the thoracic region of the back. Under these circumstances it may even be helpful if the sitting surface is tilted backward slightly. If leaning back is not possible, then the patient’s elbows and forearms should be able to rest on the desk or work surface.
If the patient is not supported either by the chair back or the desk/work table, it is better if the seat slopes up at the back, rather like a saddle, because this tilts the pelvis forward and prevents excessive lumbar kyphosis. Special chairs are now manufactured with the seat tilted forward and a knee rest, thus ensuring that the patient sits up straight. However, it is helpful to advise the patient to change sitting position as soon as back pain is felt, and chairs should be recommended that allow patients to vary their position. Specially-designed wedged cushions are also recommended. Long periods of sitting can be particularly harmful if they are compounded by jolting, for example when riding on lorries or tractors (the shock absorption and suspension on such vehicles should therefore be as smooth and efficient as possible).
It is important that the height of the desk or work table is on a level with the elbows when the patient is sitting upright with upper arms vertical. If the chair has forearm rests, these should be adjusted to the height of the freely hanging elbows. For work at the computer, it is also important that the monitor is positioned so that the patient’s gaze is not directed up or down or to one side.
Like forward-bending of the trunk, head and neck anteflexion can also pose problems in the long term. Care must therefore be taken to ensure that this head position
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