They can’t dampen the forces enough and then the forces come up through the spine and that’s what creates degenerative changes or the injury. Component number 3. In order to understand what happens to the aging spine, we need to know what happens to young, healthy spine and when injury starts to occur and identifying patients before that actual injury occurs. The spine itself is under forces. We’ve decided that. But what ends up happening is that a number of things start happening after we grow up a little bit and aren’t doing sports on a day to day basis. When we’re young and we’re in high school, we’re playing sports every day or we’re out in the back yard, everybody’s active and muscles are strong and flexible and you really don’t care what you’re doing and you injure yourself. The idea is that we get older and we start getting a job, we got other priorities, we got families. And the idea is that our activity level starts to go down. We start working out then just on weekends, we still think that we can run marathons or play taekwondo and you start injuring knees like me, things like that. The idea is that as a result of that you start getting aches and pains. Those aches and pains are little bit of a warning sign that certain things are happening. In general, when it’s just back pain, most of the time in the initial phases here, it’s an injury to the muscles or the ligaments and you get over it. You wait a few days, you don’t even see a doctor usually and it just goes away. You initially have a contribution of the muscles and ligaments injury. But then two other things start happening and they are, you start to get weakness of the muscles that are surrounding the spine. Cause again, if you don’t use it, you lose it. You generate forces, walk around all day, well, what’s generating the forces? Your legs. Your legs stay relatively strong as your activity level goes down. Those muscles in your legs stay strong, the weakness in your core creates the forces now instead of generating from your core muscles out to generate your power and forces during an exercise activity, and now the muscles in your legs are generating forces and causing further and further damage to your spine. This is core. Decrease meaning strength. And then your lower extremities no change in strength or minimum. The last component though is flexibility.

I cannot stress that one enough. The idea is that, especially when you’re an athlete, you use a lot of muscles and especially with running one of the most strong muscles that you rely upon for your exercise and activity are your hamstrings, those muscles in the back of your thighs. And as your activity level goes down those muscles get really, really tight. And they are not very flexible anymore. The idea is that if you’re going back to the principle of the spine now, how does that influence it? The idea is that if you’re moving and bending forward to do any type of activity, whatever it is, and your hips are not now moving, and you’re kind of stuck, then what do you move? Your back. And that starts putting additional pressure where? On that front joint being the disk. That’s pretty important to understand. Again, if you’re not moving through the hip which is the next joint below the spine, then it starts influencing your spine. If the hamstrings are not letting you bend over at the hips and they’re stuck, they you’re going to bend at the waist. What ends up happening is that disk, you start pushing…putting pressure through that jelly donut, the jelly squirts out. Anybody know what’s that called? Herniation. The disk herniates. That hurts but you’re young, you survive, keep going, you don’t go see the doctor. 5 years down the road you’re feeling a little bit better. That jelly itself probably stays a little bit there but essentially the jelly on the inside of the jelly donut starts to dry up a little bit. Now this disk herniation, HNP which is a herniated nucleus pulposus, is the big issue. That thing heals up. Now what we’re dealing with here is repeated episodes that are continually getting worse, either severity wise or just biomechanically. And they start taking toll, and toll and toll again. Yeah, you continue to get over it but each episode is taking its toll. So now we’re going to go down to the aging spine. Now what’s happening here? That disk kind of remodels a little bit and although that jelly starts to reabsorb a little bit, the disk itself, just because of repeated forces through it starts to do  this thing where it kind of starts to look more like a pancake rather than a jelly donut. Starts to flatten out. As the result of that jelly starting to dry up just because of age, then it’s not dampening the forces that are going through that [inaudible]. So, [inaudible] they identified that you can’t injure or change biomechanically one joint of the spine without starting to affect the others. Inevitably what ends up happening are these little hinge joints start become arthritics and they start to enlarge too. Now your core muscles continue to get weaker. There’s that imbalance. The lower extremities are still doing pretty good to maintain you, you still have repeated injury to your first and second line of defense to the spine. Now there’s a different type of flexibility issue. Because now you’re less and less and less active. And when you are less and less and less active, what are you doing? You sit. Right? You sit a heck of a lot more. I know. I need to sit down every time I go see a patient. I take a seat as soon as I walk in a door. The idea is that unfortunately something happens with the flexibility when you sit for too long. Also when you lie on your side when you’re sleeping kind of fetal position but inevitably when you sit, the muscle that actually helps you flex that leg of yours, called the hip flexor, gets tight.

Now you not only have that tightness in your hamstrings but now you’re getting tightness of those hip flexors. So when you stand up you’re like… walking your hands all the way on up. Now what happens to the spine? As you are instead of bending forward putting pressure through the disks, cause you can’t stand up straight, those hips are laxed, you stand back and now you’re putting pressure more on those little hinge joints. What are those little hinge joints called? Facets. What’s the technical term? Zygapophysial joints. Alright. What ends up happening, those Z joints grow and grow and grow. They are not truly growing but they are laying down bone and calcium deposits and bone spurs. That disk starts to flatten out more and more and more. And the end result is, look that happens to that canal where those nerves live. That’s’ spinal stenosis. That’s’ the biggest issue that we’re worried about in the aging spine. Back pain, yeah. Muscles, ligaments, those Z joints create back pain. The thing I am concerned with is always the nerves. That’s’ what people go to surgery for. That’s’ what we’re trying to prevent. Bottom line is, what do we do? Well, if you don’t use it you lose it. The bottom line is that first stage first evaluation. The idea is that we need to figure out, biomechanically everybody is different, I’m giving you just kind of general guidelines what kind of gets tight over time, what kind of gets weak over time but everybody is an individual. We need to treat you as such and we need to come up with a specialized exercise program to cross train so that no matter what your functional activity is that you want to do, again, whether it’s washing the dishes or running the marathon, we need to train you appropriately to do that activity. It’s very sports specific. That’s what we understand as being the most common way for us to describe, it has to be what you like to do.  If your goal is to do this versus this, tow totally different patients, we need to come up with a reasonable goal to achieve these things. The idea is that having a good therapist is the most critical component. That’s’ why this video is not all end all. It’s called Physical Therapy Assistant for a reason, the assist of physical therapist, but nothing replaces having the therapist look at you and say “Did you have a knee injury?” “20 years ago I did. Why would that be an issue?” Well, again, if you don’t truly recover from an injury in your legs, it starts impacting your back. The bottom line is this, you know, I as a physician like you to put you in one of two categories when you come in to see me. You got back pain, again, what do we use? We use NSAID medications to reduce the inflammation of those arthritic joints of the muscles and the ligaments, sometimes we use muscle relaxants. Once we get things to calm down, we start [inaudible] rehab program. The soon as we can. If there are ridiculous symptoms meaning those nerves are involved in some way, were on a different page here.

We need to take a little time, we need to get things to calm down in order for you to have success in increasing your activity. What I mean by success in reducing the nerve irritation varies greatly patient by patient. Sometimes you come in with that sciatica, everybody knows, thinks, they know what sciatica is. But in general sciatic nerve is just the nerve and then the irritation of that nerve. But in actuality the idea is that a pinch of a nerve here or an irritation of the nerve here could be of variety of different factors. Is there mechanical pressure, is there just chemical inflammation, [inaudible] arthritic. In which case the idea is that we give you anti-inflammatory, a lot of times we start off with non-steroidals, but sometimes we have to use steroids or injections of steroids to get things to calm down. The key component that I love in my business is that narcotics don’t work for this. They just don’t help pain that is nerve related. It’s been shown. So I don’t give any narcotics. I don’t think the work very well. There’s a very good use for narcotics, for other things, post surgically, for musculoskeletal injuries that are a component of that but I find that using a number of different medications to reduce inflammation, getting the muscles to relax, in addition to non-narcotics can be the main way to decrease the irritability so that you can have better success integrating into an exercise program that is sports specific no matter if it is tennis or pickleball.

Q: How does osteoporosis affect the spine?

Very good question. First and foremost there is, I’m not saying you have this, there is a little bit of a misunderstanding or miscommunication because there’s a confusing thing. Osteoporosis versus osteoarthritis. They both sound very similar but they are very different. First and foremost these joints back in here are kind of like an osteoarthritic issue. Osteoporosis is a density issue with the bones themselves. It really doesn’t impact as far as what we’re talking about here biomechanically unless those bones start to fail. Which is kind of like a completely different talk and what that failure of the bone essentially means is it starts to fracture. But sometimes we need to let that body heal. When there’s fractures involved, all bets are off. Sometimes even narcotics do work for this. That’s my exception. The idea is that there are additional treatments that are used for osteoporotic fractures. We can inject cement into the bone and cause that bone to become solid. These are things Dr Wagner, our spine surgeon does but the idea is that there needs to be an understanding that there’s two different things here that are kind of similar in name but very different in their effects on the spine. Osteoporosis versus osteoarthritis.