Advanced spinal movements (ASM) as manipulative treatment in back pain and promotion of spinal column

The human back is composed of a complex structure of muscles, ligaments, tendons, disks, and bones, which work together to support the body and enable us to move around. The segments of the spine are cushioned with cartilagelike pads called disks. Problems with any of these components can lead to back pain. In some cases of back pain, its cause remains unclear. Low back problems affect the spines flexibility, stability, and strength, which can cause pain, discomfort and stiffness. Approximately 80% of individuals will experience an episode of lower back pain at some time during their life. Lower back pain is the fifth leading reason for patients visiting a doctor and the leading cause of work related disability. However, the underlying cause is usually not serious and may not even be identified by the doctor. Lower back pain is most common in patients between the ages of 20 and 40 years, but can be more severe and disabling in elderly patients. The ASM technique was implemented in private clinic with aims to increases the strength, stability & flexibility of spine & prevent the different kinds of back problems. As the pain was relieved almost and the patients will be encouraged to practice the ASM technique regularly, even after the pain has gone, to prevent back pain/problems recurrence and promotion of spinal column.

The back forms the axis (central line) of the human body and consists of the vertebral column, spinal cord, supporting muscles, and associated tissues (skin, connective tissues, vasculature, and nerves). A hallmark of human anatomy is the concept of "segmentation," and the back is a prime example. Segmentation and bilateral symmetry of the back will become obvious as you study the vertebral column, the distribution of the spinal nerves, the muscles of the back, and its vascular supply. Functionally, the back is involved in three primary tasks, as follows: • Support -The vertebral column forms the axis of the body and is critical for upright posture (standing or sitting), as a support for the head, as an attachment point and brace for movements of the upper limbs, and as a support for transferring the weight of the trunk to the lower limbs. • Protection -The vertebral column protects the spinal cord and proximal portions of the spinal nerves before they distribute throughout the body. • Movements -Muscles of the back function in movements of the head and upper limbs and in support and movements of the vertebral column.

Surface Anatomy
• Vertebrae prominence: the spinous process of the C7 vertebra, usually the most prominent process in the midline at the posterior base of the neck. • Scapula: part of the pectoral girdle that supports the upper limb; note its spine, inferior angle, and medial border. • Iliac crests: felt best when you place your hands "on your hips." An imaginary horizontal line connecting the iliac crests passes through the spinous process of the vertebra L4 and the intervertebral disc of L4-L5, providing a useful landmark for lumbar puncture or epidural block. • Posterior superior iliac spines: an imaginary horizontal line connecting these two points passes through the spinous process of S2 (second sacral segment).

Vertebral Column
The vertebral column (spine) forms the central axis of the human body, highlighting the segmental nature of all vertebrates, and usually is composed of 33 vertebrae distributed as follows • Cervical: seven total; first two called the atlas (C1) and axis (C2).
• Thoracic: 12 total; each articulates with a pair of ribs.
• Lumbar: five total; large vertebrae for support of the body's weight.
• Sacral: five fused vertebrae for stability in the transfer of weight from the trunk to the lower limbs.
• The actual number of vertebrae can vary, especially the number of coccygeal vertebrae.
The atlanto-occipital joint permits flexion and extension (e.g., nodding in acknowledgment), and the atlanto-axial joint allows side-to-side movements (rotation; e.g., indicating "no"). This is accomplished by a uniaxial synovial joint between the dens of the axis and its articulation with the anterior arch of the atlas. The dens functions as a pivot that permits the atlas and attached occipital bone of the skull to rotate on the axis. Alar ligaments limit this side-to-side movement so that rotation of the atlanto-axial joint occurs with the skull and atlas rotating as a single unit on the axis

Material and methods
A study was conducted at my private clinic "Om Ayurveda & Yoga Health Centre", Davanagere, Karnataka, India. Total 60 cases with the age between 20-50 years were selected, out of which 38 are females, and 22 are males were visited to clinic with the complaints of back pain.
ASM sessions with a therapeutic focus were held daily for 60 min in morning sessions directed by me. Each session began with deep breathing exercises and relaxation techniques progressing to poses designed to begin with stretching and move into strengthening [ Table 1]. The session ended with meditative relaxation. The first week slow & mild session emphasized restorative poses and the second week session was more movement based. The predesigned ASM program progressed from simple to more challenging movements over the 4-week course. Modification for restricted movement or painful positions was provided as needed. Safety issues were monitored.

Inclusion criteria: back pain due to
Low back pain, the most common musculoskeletal disorder, can have various causes. Physical examination, although not always revealing a definite cause, may provide clues to the level of spinal nerve involvement and relative sensitivity to pain. The following causes are identified most often:  (Fig. 1) & other essential movements (C, D & E) of the spine are flexion, extension, lateral flexion (lateral bending) and rotation (Fig. 2 & 3) are starts with 2-3 rounds with slow motion in beginning and gradually increased up to 10 round counts and the speeds up to medium level. Continue the procedure for 30 days.
The greatest freedom of movement occurs in the cervical and lumbar spine, with the neck having the greatest range of motion. Flexion is greatest in the cervical region, and extension is greatest in the lumbar region. The thoracic region is relatively stable, as is the sacrum.

Results and discussion
The mean age of all subjects was 35 years, most were married. The mean body mass index (kg/m2) was 25.5, which is considered overweight. The average duration of the pain was greater than 3 months. The subjects identified the most common reasons for low-back pain as long standing working women, long time sitting without movements, bending or lifting injuries, work-related mild strains and unknown.    We have observed after four weeks of ASM as per our regimen, the patients were relieved completely in 85-90% significantly in 15%, moderately in 10% and slightly in 6%. Patients reported no relief in 2% and pain. The result is very significant at p <0.01. ASM helps to relax the back muscles, releases stiffness at the back and strengthen the back muscles and it improve the movements & posture. Care must be taken that movements/exercises do not make back pain worse.
The patient will be encouraged to practice the techniques regularly, even after the pain has gone, to prevent back pain recurrence and promotion of spinal column. Intensity of pain  Grade   1  No pain  00   2  Occasional pain  01   3  Intermittent pain  02   4  Frequent pain  03   5 Continuous pain 04

Conclusion
Advanced spinal movements are very good for individuals with back pain, because it does not have any risk of future back injuries or work absence. Substantial use ASM exercise as a therapeutic tool to improve impairments in spinal flexibility and strength. This study has improvements in pain ratings after ASM, and we sure that ASM can lessen the behavioral, cognitive, affect and disability aspects of back pain syndromes.

Acknowledgments
Acknowledgments must be inserted here.
I would like to express my thanks of gratitude to our participants (patients) to do this wonderful study on the topic "Advanced spinal movements (ASM) as manipulative treatment in back pain and promotion of spinal column" which also helped me in doing a lot of Research.

Statement of informed consent
I Dr. Manjunatha NS author of this article, herewith I am giving the statement of conformed consent of all individual participants of this study.