- Discopathy - characteristics of the disease
- Causes of discopathy
- Degrees of damage to the intervertebral disc
- Conservative treatment
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Discopathy is a popular cause of back pain, especially in the lumbosacral region, although it also occurs in the cervical and thoracic spine. Occasionally, lumbar discopathy causes pain that radiates to the hips and legs. The cause is a bulging or degeneration of the intervertebral disc, which irritates the surrounding muscles, nerve roots, or other structures of the spinal canal. Discopathy is the initial stage of degenerative disease of the spine.
Untreated discopathy leads tosensory disturbancesand evenmotor skillsas the so-called dropping foot. Discopathy should therefore be treated not only in the period of exacerbation of the disease, which is manifested by pain, but above all, to prevent its recurrence.preventive exercisesand work ergonomics play a key role in the treatment and prevention of discopathy.
Discopathy - characteristics of the disease
Discopathy isa disease of the intervertebral disc , which is oftenone of the first stages of degenerative spine disease . The term discopathy is commonly defined asnucleus pulposus herniaof the intervertebral disc of the spine. It consists in emphasizing the nucleus pulposus, whichpresses and irritates the spinal roots, spinal cord or other structures of the spinal canal . Pain is caused by mechanical pressure or low pH of the nucleus pulposus, caused by metabolism that is poor in oxygen.
Causes of discopathy
According to Christian Georg Schmorl, a German physician and pathologist,in most people over 30(and often even earlier)in the intervertebral discs there is marked degenerative changes .A damaged intervertebral disc can be repaired only in growing people . In adults, damaged areas are filled with defective fibrous tissue, which - to make matters worse - may turn out to be a good substrate for the formation of calcification, and even bone, because osteoblasts from the adjacent vertebral bodies penetrate into it. In this way, a discopathy may be the first step towards the bone fusion of adjacent vertebrae (known as biological spondylodesis).
Discs are damaged most oftenintervertebral discs in the lower cervical and lumbar region- that is, where there are secondary curvatures of the spine, and the intervertebral discs are the thickest (and thus - provide a greater range of motion). Secondary curvatures of the spine arise when a person adopts an upright body posture. The result is heavy loads - especially on the lumbar spine. Anydegeneration of the nucleus pulposus of the intervertebral discs is therefore the price that man pays for the evolutionary adoption of an upright body posture .
However, as Jerzy Stodolny believes, the statement that mass problems with back pain are the result of a person taking a vertical position is not a satisfactory explanation. This would mean that nature was wrong. And as you know - the nature of this kind of mistakes does not make. The causes of the epidemic should therefore be looked for elsewhere. According to Stodolny, the most convincing and probable arecauses of overloading . Ihe does not mean one-time overloads, but the processes of wear and tear of individual spine elementsextended in time. Moreover,this processaccording to Stodolnyis accelerated and excessive in the conditions of modern civilization , because nature has not adapted the spine to the conditions it has created for itself and in which it is now man lives. "Repeated and imposing physical and mental loads related to the contemporary shape of everyday life, work, sedentary leisure activities, overloads, as well as civilization facilitations, adversely affect the musculoskeletal system, including the spine" - claims Stodolny.
Artur Dziak agrees, who questions the view that the main cause of discopathy (and other injuries of the intervertebral discs) are single overloads, and the most common of them are spinal flexion injuries. He cites studies according to which about 40 percent of patients with lower back and lumbar pain do not have any provoking trauma. And those in whom injuries are the direct cause of the aforementioned pains most often observed previously intensified precursor symptoms. "Experimental studies showgreat resistance of he althy intervertebral discs to the load . When high forces are applied, the end plates and vertebral bodies are primarily damaged; reconstruction of the pulmonary nucleus prolapse under experimental conditions is almost impossible "- writes prof. Dziak.
The conclusion is, of course, not thatpathological pressures do not damage the intervertebral discs. Allhowever, it indicates that the primary cause of any damage (including discopathy) of the intervertebral disc is tissue wear combined with other (often congenital) predispositions of the organism . And sincethe lumbar spine is one of the most overloaded places in the body , any weakening of its natural endurance makes itself felt quickly. What is worse, it is not known whyover the years the nucleus pulp gel changes its chemical structure , and with it its hydrostatic properties, to the detriment of many functions of the intervertebral disc. However, the current state of research indicates that in disc pathologies, innate strength (and more specifically - its level) plays a greater role (in percentage among patients) than the size and nature of the pressure. It is she who most often decides how quickly the first pathologies and degenerations appear, followed by subsequent damage to the intervertebral discs.
The changes initiated gradually eventually weaken the disc so much that loads it would normally withstand without any negative consequences may damage it.
Degrees of damage to the intervertebral disc
Changes occurring as a result of damage to the intervertebral disc are divided intothree stages . The transitions between them are not sudden, each of them usually lasts for many years. This is due to the fact that intervertebral disc disease often begins at an early age, when the semi-liquid nucleus is elastic and flexible. However, it becomes dehydrated over the years and its elasticity decreases. The started degenerative changes (regardless of age), however, prevent the return to normal and lead - faster or slower - to the progression of the disease.
Period I-damage ,deformationifragmentation of the nucleus pulposus . Pathological changes occur long before the pathological dislocation of the nucleus pulposus and the rupture of the fibrous ring. The first stage of the diseaseis the breaking and disintegration of the nucleus , fragments of which lie slowly in a semi-fluid environment inside the fibrous ring. At the same timethe fibrous ringitself (especially in the back part) is softened and weakened, which is not a separate formation from the nucleus, but merges with it (the nucleus smoothly turns into a ring).
At this stage of the disease, the fibrous ring tears slightly, butthe damage worsens over time . It is also more prone to injury, or even complete rupture, when subjected to a higher load (whichwould not be dangerous for a he althy intervertebral disc). On the other hand, in the diseased testicle, the ability to absorb fluids (even when relieved) and retain them under pressure decreases. As a result, it becomes more susceptible to injury, and its fragments move backwards under pressure and consistently hollow (weakening, stretching and tearing) the fibrous ring.
The disintegration of the nucleus itself (not yet shifted)has a great influence on the mechanics of the intervertebral disc .The damaged nucleus ceases to transfer the pressure evenly and symmetrically on the fibrous ring and the border plates of the vertebral bodies , thereforethe disc loses its shock-absorbing functionand does not effectively support the vertebrae in every range of motion. As a result, the fibrous ring is not subjected to varying pressures in different planes, but is permanently compressed in one direction (usually posterior and posterolateral). This compression is the main factor causing the degenerative changes and, consequently, the rupture of the ring.
Period II-displacement of the nucleus pulposus . This is another long-term stage that can be, if not inhibited, at least slowed down with appropriate therapeutic treatment.Even complete rupture of the fibrous ring does not have to lead to protrusion of the nucleus pulposus . And it certainly doesn't have to happen soon.
The nucleus pulposus, however, is under the influence of constant pressure, which constantly pushes it backwards. They are held in place by the fibrous ring and the posterior longitudinal ligament of the spine. After breaking the ring, the pressure inside the intervertebral disc will push the nucleus outwards, and even more so will prevent it from returning inwards. The induction of the nucleus into the broken fibrous ring will be all the easier as the integrity of a he althy nucleus is guaranteed by the mesh of fibrous tissue that connects to the ring and the end plates. The diseased nucleus is subject to fragmentation, and the torn off fragments under the influence of pressure can be more easily squeezed out of the inside of the ring.
The testicle most often bulges in the posterolateral direction, right next to the longitudinal ligament. After getting outside the fibrous ring, it is usually curled, flattened and moved under the longitudinal ligament along the course of its fibers or laterally - along the root towards the intervertebral foramen. Together with the nucleus, the fibrous ring may also be torn, which causes the whole nucleus to shift backwards (the so-called massive protrusion). There are also bilateral protrusions. Squeezed fragmentsthe nucleus pulposus can wedge between the edges of the vertebral bodies and block them. They can also enter the spinal canal.
The second stage of the intervertebral disc disease ends when the fragmented nucleus is completely pushed out or its fragments become fibrotic to the extent that they cannot move . Appropriate and early treatment is based on: in order to cause fibrosis of the nucleus inside the fibrous ring.
Period III-fibrosis of the intervertebral disc . In the last stage of the disease , the repair process begins . It is true thatis still in the process of degeneration of the entire intervertebral disc , but the processes of fibrosis are gaining an advantage over the processes of nuclear and ring breakdown. And since thenucleus very rarely extends completely beyond the fibrous ring(the bump usually only affects a fragment of the nucleus), this process takes place largely inside the diseased intervertebral disc. However, the displaced parts of the nucleus are also subject to retrograde changes (loss of elasticity, hardening, and finally fibrosis), which may calcify and ossify, creating bone outgrowths.
The retrograde fibrous ring contracts and hardens, andreduces (and sometimes even disappears) the mobility of the vertebral bodies . During this periodthe interbody gaps become narrowing , which has a negative impact on the inter-process joints (increases the load on the joints, which in turnleads to degenerative changeswithin them, periarticularfibrosisandsclerotizationandformation of bone adhesions ).
Changes in the third stage of the disc disease causestiffening of the spine joints .The deficit in mobility is usually associated with pain relief . Unless the intervertebral disc is damaged at a different level, which is quite common in this disease.
Course of the disease
The course of intervertebral disc disease is typical -is characterized by alternating periods of pain and relative peace . Pain attacks occur more frequently and are more severe if the disease is not treated.Acute pains can disrupt the lifestyle for months or even years . They can appear for no apparent reason, not only after an acute injury or severe strain on the spine, but even after sneezing or some other completely innocent movement.
The duration of pain depends on the patient's behavior and treatment. Sometimes the attack of pain is preceded byhe is the symptoms that herald him. If the sick person realizes and restricts their activity, they shorten the period of immobility and alleviate suffering. However, it can also aggravate them if he tries to get rid of the ailments quickly with the help of physical therapy, blockages or spine manipulation, because this way it is easy to deepen the damage to the diseased joint and worsen the situation. During the period of pain exacerbation, similar effects have excessive physical or work activity, which often contribute to pain recurrence.
In the third stage of the disease, pain is less frequent and appears only as a result of a clear trauma.Acute pains usually occur in periods I and II . In the first periodthey usually worsen after prolonged sitting or standing . In the second period, until their occurrence , only the movements of the lumbar spineare enough. Attacks are so strong that they disable normal functioning, but they pass spontaneously and are shorter than those in the first stage of the disease.
Self-healing of disc disease is apparent . Usually they concern patients who experience periodic recurrences of symptoms, but being aware of the dangers ahead, they strictly adhere to an appropriate lifestyle.
"A patient who, after a period of severe low back pain, develops a relapse should not expect to find someone who will relieve him of his dysfunction or suffering forever, but should mainly rely on himself. This means that after obtaining the appropriate advice from an orthopedist - expert in spine diseases (!) -you need to self-medicate"- says Artur Dziak.
The position that relieves the intervertebral discs most is lying down. The use of passive therapy consisting of "bed-stuck" combined with physical treatments and pharmacotherapy may have a terrible effect on the patient's psyche, and will certainly have a negative impact on his motor organ. That is why Artur Dziak recommendsmaintaining an active lifestylewithin the limits of physical abilities, andduring an exacerbation of pain - 1-2 days of lying in an appropriate bed .
The patient should be aware that the conservative treatmentkinesiotherapy, physical therapy and pharmacotherapydo not cure the disease, but allowto alleviate its symptoms and prevent relapses . Conservative treatment also includes influencing emotional and nervous factors, because the improvement of the patient's quality of life largely depends on the state of the patient's psyche, self-confidence and the belief that they can function normally with their disease,regardless of the help of third parties.
Physical exercisesis the most popular (and if properly selected and systematically performed, also the most effective) form of therapy used in discopathy of the lumbar spine. This does not mean that they can completely heal the damaged intervertebral disc, but they can reduce pain sensations and spine dysfunction.
The muscles of the torso are in a state of constant activity (even when lying down, even though they are called postural muscles). The body posture is mostly influenced bysynergistic work of the torso extensors and flexors . During the exercises, however, it is not possible to focus solely on one of these two groups. The other core muscles should not be neglected either. A well-chosen exercise program takes into account the most effective stabilization of the lumbar spine during exercise and aims tocreate a muscular corsetthat will relieve the intervertebral discs and prevent overloading other static stabilizers (ligaments, joint capsules) and active (muscles).
The success of the therapy also depends on the cooperation and commitment of the patient himself.Therapeutic sessions are conducted until the patient understands and masters the appropriate exercises. Then the patient enters the self-healing phase, in which he independently performs exercises at home . She also follows the therapist's other guidelines all the time andadjusts her lifestyle to the requirements of the disease .The self-healing phase never ends .
The most common cause of deepening the damage to the intervertebral disc is the use of the so-called proven, supposedly always effective exercises. However, only individualized treatment is effective - adapted to the patient's ailments and possibilities, and not carried out according to a predetermined scheme. Individualization includes the fact that the patient in the self-healing phase undergoes periodic checks at the therapist, who assesses whether the exercises performed by the patient require modification due to the progress made. First of all,individualization is about creating an appropriate exercise program - tailored to the needs of the patient . For example, a patient with intervertebral disc nucleus posterior dislocation should not perform strength exercises in extreme flexion or extension (hyperextension) positions of the spine, as this may aggravate or accelerate disc damage. And strengthening the torso flexors and extensors themselves, bypassing other muscle groupsstabilizing the lumbar spine, may have a counterproductive effect, i.e. destabilize the spine.
The starting point for creating proper programs for both prevention and treatment of discopathy is understanding the mechanism of damage. Usually, it consists insumming up of microtraumas and overloads , single injuries with high strength are less frequent (most often it is lifting heavy loads, especially with the long arm of the lever). In addition, there are incorrect positions - especially the position of full bend, which provokes trauma (the stabilization mechanisms are weakest in this position). But also other extreme positions of the spine. Most often, the injury itself occurs during completely innocent activities, such as lacing a shoe, sneezing or picking something up from the floor. The real causes of such injuries, however, are in the vast majority of cases the build-up of microtrauma, overload and other factors mentioned above.
The main goal of the therapy is to restore the stability of the spine, rebuild the patient's proper proprioception and sense of the patient's body in space, as well as make the patient aware of how much it influences the effectiveness of the therapy . Since there is no universal exercise that develops all the muscles of the torso stabilizing the spine, it is necessary to perform a system of exercises adapted to the phase of the disease, its causes, as well as the level of training and performance of the patient. These exercises should involve antagonistic muscle groups, and not only one-sided. During their execution and afterwardsthe patient should not feel pain . Exercise should develop both muscle strength and endurance, but for stabilization, endurance is more important, as it weakens faster and plays a more important role in stabilizing the spine . Smooth, gentle movements should be used asjerky and violent movements may provoke injury . It is recommended to exercise with minimal stress on the joints of the spine - that is, mostly lying down. It is also importantwork on the flexibility of the spine , and thus -also on the flexibility of the hip and knee joints.Therapy support is also provided by needs and the patient's possibilities aerobic exercises (it can even be brisk walking), which improve the oxygenation of all components of the spine and have a positive effect on the mental state of the patient.
The key to preventing damage to the intervertebral disc, as well as preventing recurrence of ailments from an already damaged disc, arestrong abdominal wall muscles , because they protect againstdevelopment of hyperlordosis and reduce the harmful excessive pelvic tilt. However, when strengthening the abdominal muscles, remember to assume the right position while exercising. The so-called crunches (sit-ups with bent torso, hips and knees) strengthen mainly the rectus abdominis muscle; crunches with a straightened torso - mainly the lumbar muscles (increasing the pressure on the lumbar spine - therefore they are not recommended). It is contraindicated to simultaneously raise straightened legs, which this exercise significantly increases the pressure exerted on the discs of the lumbar spine.Exercises in lying on the side are recommended , which activate the often neglected oblique muscles of the abdomen and trapezius muscles (decisive for the stability of the lumbar spine). To balance the work of the flexors and oblique muscles, training of the spine extensors is also necessary. Commonly used so-called Airplanes (simultaneous lifting of the upper and lower limbs while lying on the stomach) is not advisable, however, due to the excessive load on the lumbar spine in this position. Due to the fact that in discopathy the spine extensors are often tense, they should be practiced (sometimes they should be abandoned - depending on the individual needs of the patient) at the very end, after strengthening, stretching and relaxing the remaining muscle groups. Exercise must be done regularly, preferably daily.
In physiotherapy, various methods are used to help patients with damaged intervertebral discs. They can be divided intosymptomatic(mainly in patients with acute pain) andcausal(preventing relapse and relieving chronic ailments). We can also distinguishposes, manual therapies and sets of exercises . For many years, the McKenzie method was also popular, which in the most general terms consists in facilitating the absorption of the prolapsed pulp nucleus and reducing its pressure on the nerves and other surrounding structures. Currently, it is more and more often criticized because of its too one-dimensional and not global approach to the problem; searching for the causes of pain in only one place, while the damage to the intervertebral disc may be caused by pathologies not necessarily of the spine, but of the spine influencing. The so-called Forcing the testicle into place with positional positions, levers and exercises will therefore be of little use if the root cause of the injury is not eliminated and the biomechanical chain that led to it is corrected. Physiotherapy of a patient with a damaged intervertebral discit is - as you can see - a complicated process and requires extensive knowledge of the whole body, because the causes of back pain do not necessarily lie in the spine. The most important thing is to choose individual therapy and monitor its progress.
Physical therapy is a complementary element of conservative treatment, in which kinesiotherapy plays the most important role. However, the action of physical factors supports other forms of treatment and produces the desired therapeutic effects in both acute and chronic pain relief.
One of the methods supporting kinesiotherapy is superficial thermotherapy, which reduces pain and contractility of muscles and prepares them for exercise. Thermotherapy treatments (including infrared, paraffin compresses, dry baths, saunas) should be used in accordance with the individual needs of the patient, bearing in mind their impact on the patient's body. The local reaction, which consists in the expansion of blood and lymph vessels in the heated area and its vicinity, is more often desirable in therapy. Increasing tissue temperature is combined with increased blood flow, which relieves pain and reduces muscle tension. The general reaction occurs as a result of overheating of the whole body, and therefore requires a much greater energy expenditure from the patient (therefore, be more careful when using it). Overheating the whole body, however, has a beneficial effect onreducing muscle tension, which may be beneficial especially for patients in the phase of exacerbation of pain associated with the so-called falling out disk .
When applying heat therapy (especially in the case of a general reaction), remember about the preservation of blood vessels under the influence of temperature, which is determined byDastre-Morat law : "thermal stimuli (cold or heat), acting on large areas of the skin, they cause the opposite behavior of the skin vessels in the chest and abdominal cavity. The vessels of the kidneys, spleen and brain react the same way as the vessels of the skin. ' This means that if the overheated blood vessels in the skin dilate, the large vessels in the chest and abdomen narrow. And when the blood vessels in the skin constrict under the influence of the cold, the large blood vessels in the chest and abdominal cavity dilate. Just like the blood vessels of the skin, only the vessels of the kidneys, spleen and brain behave.
In addition to the effect of heat, thermotherapy also includes cryotherapy (treatment with cold), whichrelieves inflammation of muscles and soft tissues and has an analgesic effect . Cold in discopathy is usually usedtopically, as when used generally it increases tension or causes muscle twitching. When applied topically, it can even help to relax them by reducing the pain that often causes habitual tension. After local cryotherapy, it is also recommended to perform kinesiotherapy exercises, provided that the patient is not going through an exacerbation state, during which muscle relaxation is recommended.
For this purpose, you can also use high-voltage pulsed galvanic electrostimulation, which shouldweaken muscle spasm in the painful areaof the spine, and thus -reduce swelling and pain complaints . This is due to thereduction in the excitability of nervesandunder the anode . That is why the painful area should be treated with the anode, not the cathode, in this treatment. It should also be remembered thatin the subacute stage of the disease, weaker doses, and in the chronic - stronger . The use of small electrodes (10-20 cm square) in the paraspinal area also requires the use of weaker doses, because too strong can burn the patient. The intensity of the treatment is always adjusted (and corrected during the treatment) to the patient's feelings.
Stimulation with TENS currents helps in the treatment of chronic spinal pain syndromes, but they areinadvisable in acute pain . Remember to use them below the pain threshold and place the electrodes at the pain site, trigger point, or along the sensory nerve supplying the painful area. Stimulation can be performed even several times a day, but it is important to check its effectiveness every few days.
Among the less popular in the case of intervertebral disc disease, although not necessarily less effective, physiotherapeutic methods, the use of which should be considered, are also intradermal needle electrical stimulation (PENS) and acupuncture. Analgesic DD diadynamic currents, relaxing and warming short-wave diathermy (DKF) and ultrasounds are also used. In order to relax the muscles, massage is also used - both classic (manual) and segmental as well as whirling underwater massage.
In the treatment of back and lumbar spine pain,painkillers ,anti-inflammatory(non-steroidal and steroidal), medicationsmuscle relaxantsas well as medicationsantidepressants .
The most commonly used are paracetamol and aspirin, which have an analgesic effect, and indirectly (thanks to thepain reduction) also relaxing. Non-steroidal anti-inflammatory drugs are taken in such small doses (and for up to 4 weeks) that their action is also limited tothe analgesic effect . Painkillers are well combined with the effect of muscle relaxants - used briefly, usually at bedtime.
Less popular (because their positive impact on this disease has not yet been proven in the face of possible side effects), but some use steroid drugs - corticosteroids. More effectively than non-steroidal drugsthey inhibit inflammation and swellingin the area of the nucleus pulposus protrusion. The supportive treatment also includes antidepressants and drugs that help in sleep disorders.
The key to all pharmacotherapy, however, is the knowledge thatthe usefulness of drugs in the treatment of back pain is very limited .They can only support other, more effective healing methods for a while . However, they cannot replace them. As Artur Dziak writes: "drugs should be used depending on the individual needs of patients, and not indiscriminately prescribe the same preparations to everyone, regardless of their disease […] long-term use of drugs is the biggest obstacle on the way to proper treatment". And this is for two reasons - due to the side effectsappearing with too long use and too high doses . And also because patients believe that drugs can replace them with other forms of therapy.
The aim of prophylaxis ispreventing the occurrence or recurrence of ailmentsrelated to the disease of the intervertebral disc. And also makingyour discomfort as short as possible and as little as possiblewhen it does happen.
Regardless of the causepain always increases under the influence of mechanical factors . That is why it is so important to know the biomechanics and ergonomics of the spine. This knowledge should be acquired not only by the therapist, but also by the patient, because his behavior and commitment have an equally large impact on the effectiveness of both therapy and prophylaxis. Contrary to appearances, this does not only apply to elderly or middle-aged people, because it has been proven thatlow back pain (e.g. caused by discopathy) often affects young athletes and young workers (under 25 years of age), who they largely perform their duties in a sitting position . Especially those who neglect prophylaxis.
One of the most important elements of prevention isavoiding excessivelysitting for a long time . And if it is impossible, adjust the workplace to make it as ergonomic as possible. It is recommended to use special chairs with wide seats, which allowto change positions . With handrails and a backrest (preferably tilted at an angle of 120 degrees) that reproduces the natural curves of the spine. It is also recommended to adapt other household appliances - for example, place kitchen worktops at the appropriate height so that the activities performed with them do not require bending the torso.
If the patient lifts loads at work, he should follow a program of isometric exercises ,that will strengthen his abdominal and trunk muscles . By the way, it will increase the effectiveness of one more stabilizing mechanism - the pressure inside the abdomen and chest. At the same time, when lifting weights, he should use straight holders and straps, which will additionally strengthen the stabilization. However, relying solely on orthoses etc. is not advisable as it weakens the muscles.The use ofof thisequipment should therefore be combined with the exercises . And it should not be abused. The exercises themselves are best performed in the positions that burden the spine the least. It is inadvisable to maximally bend and carry loads in a flexion position ( not recommended for example crunches ), as well as developing excessive strength and endurance of the ilio-lumbar muscles ( not recommended e.g. raising straight legs in the supine position ), because it deepens the lumbar lordosis. However, the most common exercises are lying down, because it is the least burdensome for the spine. It is worth paying special attention tooblique abdominal muscle exercisesand trapezius muscles, because these groups are usually much weaker than the flexors and extensors of the torso. Many exercises will therefore be performed in the side lying, not the front or back - which has been accepted as the most popular.
Counteracting lumbar pains is alsofighting obesity , which increases the axial loads and extends the lever of the strength of the torso. These are other factors overloading the spine and causing microtrauma, which - especially in people who lead a sedentary lifestyle and perform heavy physical work - are largely responsible for damage to the intervertebral disc. In addition, it is also influenced by independent factors, such as sex, age or deviations in the structure of the musculoskeletal system. And also psychological factors.
Substantial impact on the development of disc diseaseintervertebral disc, as well as for many other pathologies of the spine and the musculoskeletal system, hasmaintaining the correct body posture- both during everyday life activities, as well as during work, recreation, sport or sleep. This is facilitated not only by properly adjusted equipment (furniture of the right height, a firm and flat mattress, fitted footwear, etc.), but also by strong and enduring muscles and useful habits.Learning the correct body posture is one of the most important elements of prevention . Without this, it is difficult to expect that the other elements - such as exercises, pressure belts or the patient's proper mental attitude - will have the desired effect. This learning, despite a few basic principles, should not be carried out according to a predetermined scheme, but must be individualized - adapted to the possibilities and needs of the patient. Also to the psychic possibilities. One of the basic factors determining the success of prophylaxis is the patient's understanding of its purpose. Only then can he consciously learn the right actions, appropriate exercises and finally he can take care of his own he alth with commitment.