Chiropractors and physiotherapists use a variety of methods to examine patients presenting with spinal disorders, such as history taking and physical examination. One aspect of physical examination commonly used is the assessment of spinal stiffness, a common and bothersome musculoskeletal complaint. However, its measurement and clinical relevance is somewhat unclear.
What is spinal stiffness?
Spinal stiffness can be defined as the subjective awareness of tightness and restricted spinal movement. Stiffness can be felt throughout your spine—cervical (neck), thoracic (mid-back) and lumbar (low back) regions. Stiffness can be widespread (i.e., whole spine) or specific to a region (e.g., neck) or spinal level (i.e., vertebral segment), and can effect one side of the body or both. It can also be pathological or physiological.
The most common cause of stiffness of the spine is due to tight and injured muscles, spinal ligaments, facet joints, discs and capsules. Causes of tissue injuries include repetitive or blunt trauma, overuse or underuse and poor posture and lifting. These are physiological (i.e., musculoskeletal) causes of back pain and spinal stiffness, which affects approximately 80% of Australian’s at some point in their lives.
Patients with a musculoskeletal cause to their stiffness of the spine often describe this as initial morning stiffness that quickly reduces when they increase their daily activities. In most cases of health patients, this type of morning stiffness is due to muscles and joints. Muscles and joints thrive on movement—activating (i.e., pumping, compressing, stretching etc.) of muscles and joints helps to distribute the synovial fluid and other nutrients found within joints, and blood (that brings along with it heat and nutrients) within muscles and tendons. So, when we awake from our 6-8 hour resting sleep, the synovial fluid, blood and other nutrients and metabolites are reduced in our muscles and joints. Initially, our movements may be compromised, but quickly, as we being to become active, the fluid, blood and other metabolites normalise in our tissues.
Widespread pathological (i.e., disease-related) spinal stiffness can be due to autoimmune conditions like ankylosing spondylitis (i.e., spinal inflammation and fusing of the vertebrae) and rheumatoid arthritis (inflamed, red, hot swollen joints), and other disease including collagen diseases (e.g., scleroderma) and polymyalgia (i.e., muscle pain and stiffness). These conditions are far less common than musculoskeletal causes of stiffness of the spine, affecting approximately 2-3% of people in Australia. Another common cause of stiffness of the spine is osteoarthritis (e.g., degeneration of the spine and intervertebral dics).
How do we measure spinal stiffness?
Spinal stiffness assessments are frequently performed as part of patient evaluation in chiropractic and physiotherapy. The clinician typically will use the palm of his or her hand to press on the spine and feel for restricted movement, i.e., a posterior-to-anterior stiffness (PAS).
Interpretation of PAS measurements is complex. Clinicians often use PAS as a tool for spinal stiffness, although studies have shown that this technique is not sensitive or specific. For instance, when clinicians use PAS on the mid-back, the whole low back and ribcage rotates. Furthermore, the poor inter-rater reliability (i.e., the degree of agreement among two or more different clinicians), the lack of standardisation in PAS applying force, and measuring and quantifying stiffness complicates the situation.
The literature on the measurement of stiffness of the spine is unclear. A review on 104 studies that examined the measurement of stiffness in mostly healthy people, found there is limited evidence that: (1) practitioner-judged stiffness is associated with radiographic findings of spinal mobility; (2) stiffness of the spine is unlikely to predict patient outcomes; and, (3) there is a change in spinal stiffness and function following mobilisation or manipulation techniques in health people and mobilisations in symptomatic people.
Other studies examining the improvement of pain and disability in patients with chronic low back pain found they were not associated with measured global stiffness. However, reported spinal morning stiffness and low back pain is associated with lumbar disc degeneration.
Is spinal stiffness clinically important?
In short, yes! Stiffness of the spine helps clinicians throughout the diagnostic procedure and guides management options. It is also very clinically important if we suspect a pathological cause to your spinal stiffness.
However, in the case of simple musculoskeletal disorders, patient-perceived ‘stiffness’ may not be as clinically relevant when compared to pathological causes of stiffness. A study on 129 patients from the general population aimed to measure spinal stiffness and pain levels using a mechanical indentation devices that mimics the PAS examination found no significant relationship between the severity or chronicity of the low back pain complaint and stiffness of the spine. There was also little agreement between the stiff or tender spinal segments identified by the clinicians using palpation (i.e., clinician uses their hand to examine the joints and tissues) and the segment that measured most stiff using the PAS device.
What are some management strategies?
For uncomplicated, mechanical spinal stiffness, chiropractors and physiotherapists use a variety of clinical techniques to help reduced self-reported pain and disability. Some techniques might include active directional preference exercises, mobilisations and manipulations, stretching and strengthening exercises and modification of work, posture and lifestyle factors.
For pathological spinal stiffness, the management depends on the specific cause of spinal stiffness. For example, in osteoarthritis, patients are often prescribed pain and anti-inflammatory drugs (e.g., analgesics and non-steroidal-anti-inflammatory drugs), are encouraged to loose excessive weight to reduce strain on joints, and increase mobility by stretching and keeping up their physical exercise. Avoiding fear of movement and developing a positive attitude towards active care are also important aspects in the management of spinal stiffness in osteoarthritis.
For more information on spinal disorders, pain and dysfunction, please visit the following articles via our website:
- Mid and upper back pain overview
- Muscle pain
- Joint pain
- Thoracic myelopathy
- Thoracic spine trauma
- Thoracic osteophytes
- Thoracic bone Spurs
- Thoracic spine stenosis
- Thoracic degenerative disc disease
- Thoracic disc herniation
- Thoracic arthritis
- Thoracic foraminal stenosis
- Thoracic pinched nerve
- Thoracic facet syndrome
- Thoracic facet joint pain
- Thoracic disc bulge
- Thoracic disc protrusion
- Thoracic spondylosis
- Thoracic spondyloarthropathies
- Thoracic radiculopathy
- Thoracic discogenic pain
- Acute mid back pain
- Chronic mid back pain
- Stiff mid back
- Thoracic spine tumour
- Upper back arthritis