Low back pain has been, and continues to be, one of the enigmas of neuro-musculoskeletal medicine and rehabilitation. Roughly 60% of the American population experiences low back pain on any given day. Eight and a half out of ten adults will experience low back pain at some point in their lives. If you are reading this, the odds are very good that you or someone you know has experienced low back pain at some point in time, and will likely experience it again in the future.
Yet even with the advent of new and exciting diagnostic testing (MRI, CT, PET Scans, etc.) many people are not finding the relief they desire from traditional approaches to this modern day problem. In addition, research demonstrates that those who are afflicted with low back problems will experience problems in the cervical spine (neck) within 3-5 years, and vice versa. As well, an overwhelming majority of patients with low back pain receive a final diagnosis as having idiopathic pain. What this means essentially is that no one really knows why you hurt. Some statistics estimate that as much as 50-60% of patients with low back pain do not have a firm, accurate, anatomically defined reason for their pain.
Perspective is a Good Thing
While there are many myths surrounding low back pain, a few of my favorites are:
Myth #1: Imaging Studies such as MRI accurately identify etiology (source) of pain.
Think of it this way: An MRI is a picture which tells you about the structural integrity of the spine (vertebral bodies, facet joints, discs, dural or nerve root impingement, etc.). As an analogy, we can also take a picture of a car and see its color, make, model, etc., but the picture does not tell us whether or not the car actually “runs” properly.
The fact is that imaging studies, such as MRI, offer a structural assessment only and may or may not accurately identify the source of pain. Whatever the imaging study may be, it must be correlated with objective orthopedic physical assessment for somatic dysfunction to accurately identify the source of pain.
Myth #2: Back pain is genetic.
I personally have never read any convincing research that accurately demonstrates that back pain is purely genetic. In fact, the science of epigenetics is currently demonstrating that there are very few things that are purely genetic in presentation.
Myth #3: If you have low back pain, you are just going to have to live with it.
You do not have to live with low back pain. There is no “magic pill” that will eliminate the cause of your low back pain. Sure, anti-inflammatory drugs, muscle relaxers, and pain killers can mask the pain, but the source of that pain is still alive and well. A multi-disciplinary approach is the best option for permanent pain relief.
Heads up – Where You Hurt is NOT the Problem
There are some very real steps you can take (yes, they do require work) to get rid of your low back pain. The simple fact of the matter is that most low back pain sufferers are suffering needlessly due to the compartmentalized approach utilized in conventional orthopedics and rehabilitation. If someone is experiencing low back pain, all anyone ever looks at is the low back – completely ignoring the influence of some key higher order reflexes on the lower quarter. This is an all-too-common mistake. As Karol Lewit has stated so eloquently, “He who treats the site of pain is lost.”
In many cases of low back pain (80% plus of cases) the issue creating pain is mechanical in nature. What that means is that something in the locomotor system, from foot to head, is creating altered movement, and the low back is the loser of that game. The low back pain is not actually the problem itself. Rather, the low back is the primary site of compensation for the problem. Over time, the low back is no longer able to maintain its compensatory effort and this leads to pain.
Think Outside “The Box”
If you, or someone you know, have not been able to overcome low back pain despite the best of rehabilitation efforts, it is time to start looking where no one has looked before.
Here are some of the issues that I assess with clients that have not been able to overcome low back pain:
To quote Karel Lewit again, “If breathing is not normalized, no other movement pattern can be.” The way you breathe – your respiratory mechanics – drastically influences the health of your spine. Without the ability to ventilate, you have roughly 3-5 minutes to live. As such, it stands to reason that the body will sacrifice just about any structure necessary in the cranium and below, including the low back, to accommodate breathing.
If your breathing is not mechanically sound, it is likely that you will begin to lose lateral expansion in the rib cage. As a result of that, the thoracic spine (middle back) is likely to lose mobility and become very stiff. The areas above and below the thoracic spine, which happen to be the cervical spine (neck) and lumbar spine (low back) become “buffer zones” for the lack of movement in the thoracic spine. What this frequently leads to is lower cervical spine (C3-C7) degeneration and disc bulges and the same thing is likely to occur in the lumbar spine.
Mechanical low back pain, in my experience is frequently found coupled with dysfunctional respiratory mechanics. One scenario for this occurs when many of the accessory respiratory musculature become facilitated (chest breathing). The scalene group is one such muscle group likely taking the brunt of the load. Due to their attachment to the first and second ribs respectively, scalene facilitation will lead to an increase in superior movement during respiration, particularly when the rib cage does not move as well laterally. As an antagonistic response, the quadratus lumborum (QLO) will be facilitated and produce inferior movement of the rib cage via its insertion to the inferior border of the 12th rib. This forces the QLO to perform function that it would not normally perform, and as a result will likely develop latent and/or active trigger points. Since the QLO also attaches to the transverse processes of L1 through L4, eventually, the result will be low back pain and possible radicular pain into the glutes and legs.
Photo Credit: http://en.wikipedia.org/wiki/File:Gray145.png
Your cranium (skull) has tremendous influence over the low back. In the cranium, the sphenoid and occiput (base of skull) are mechanically linked to the sacrum (tailbone) and coccyx. If there is a lesion in the basisphenoid, the mechanics of the sacrum are going to be altered. This mechanical alteration will “trickle” up and create aberrant mechanics in the lumbar spine. Before long, the altered mechanics leads to irritation of joint structures in the low back accompanied by – you guessed it – low back pain.
Temperomandibular Joint (TMJ) Dysfunction and Malocclusion
Photo Credit: http://www.mcardledmd.com/do-i-have-tmj-.html
The subtle effects of TMJ dysfunction and malocclusion (a bite that is “off”) can easily lead to issues in the low back. Ideal function of the TMJ and occlusion provides even pressure through the force vectors of the cranium and cranial bones as well as providing an optimal position for the length-tension of muscles and ligaments of the joint. To put it simply, a jaw and teeth that line up and are mechanically sound help to keep things in the cranium and TMJ moving the way they should. Any threat to function in the region will lead to compensation.
There are 136 muscles in the head and neck region. Structural imbalance or injury to any of them can lead to issues with the temporal bone (a major cranial bone) and the mandible. According to Fonder and Guzay, any dysfunction of the mandible and its relationship with the cranium will lead to muscular spasm in the area of the upper cervical spine (C0/1, C1/2). This leads to mechanical issues at the atlanto-occipital joint (the point where your head sits on your neck). This will in turn affect the mechanics of the lower lumbar spine, particularly L4 and L5 (this occurs through something called the Lovett-Brother Relationship).
As a result, any number of issues, from shoulder pain to low back pain can manifest. “Treating” the low back will lead to poor results at best when the issue is stemming from a problem in the TMJ and/or cranium. This is another example of low back pain being the “branch” of the real issue. Here, correcting the issues at the TMJ/cranium will address the “root” of the low back pain and produce lasting pain relief.
Most people have not heard of something called an occulocephalagyric reflex. Through this reflex, the muscles of the eye can influence the position and mechanics of the upper cervical spine (C0/1, C1/2). This is important because the upper cervical spine has tremendous influence over the lower cervical spine and the lumbar spine as mentioned in the TMJ section above. Imbalances in the intrinsic muscles of the eye can therefore contribute to your chronic low back pain.
Upper Cervical Spine Issues
Upper cervical spine issues are very common. The National Upper Cervical Chiropractic Association (NUCCA) estimates that somewhere near 37% of newborns are born with atlas (C1) subluxations (basically means the atlas is not in its proper position and has various motion restrictions). Again, through the Lovett-Brother Relationship, this can and frequently does lead to compensatory issues in the pelvis, sacrum, and lumbar spine. It is possible that your low back pain is actually a neck issue!
Pelvis and Sacrum Issues
Issues anywhere in the pelvis, sacrum (tailbone), and sacro-iliac joint are often contributing factors to low back pain. By observing the clinical anatomy of the lumbar spine and sacrum, it is easy to see connect the dots and understand how the pelvis and sacrum influence the lumbar spine. One such influence is via the ilio-lumbar ligament. The ligament extends from the transverse process of L4 and L5 vertebral bodies and reaches the iliac crest. There are taut bands of this ligament which form “hoods” over the L4 and L5 nerve roots. These hoods are in fact capable of compressing those nerve roots. This can lead to pain that radiates down the leg and mimics sciatic-type pain. The main function of the ligament is to resist motion at the lumbosacral junction, especially in side-bending. Asymmetrical position of the innominate bones can alter tension through the ligament and influence the mechanics of L4 and L5 and even spinal segments above. This can easily lead to low back pain. There are countless other somatic dysfunctions of the pelvis and sacrum that can lead to low back pain. Bottom line, if your pelvis and sacrum are not doing what they should, your back will suffer.
Issues with Your Foot/Feet
The foot is commonly completely ignored in cases of low back pain. This is unfortunate as the foot and its 33 joints can contribute greatly to spinal issues in upright posture. Tiny movements in the bones of the foot can heavily influence the posture of the sacrum and pelvis. As mentioned above, the sacrum and pelvic compensations for these movements can lead to issues in the spine itself creating low back pain. Pronation (involves eversion of the heel, abduction of the forefoot, and dorsiflexion of the subtalar and midtarsal joints) and supination (involves inversion of the heel, plantar flexion of the subtalar and midtarsal joints, and adduction in the forefoot) when occurring unilaterally, have the ability to influence the rotation of the pelvis, which in turn, influences the function and mechanics of the lumbar spine. Bottom line, with about 80% of the population having foot issues, it is not at all far-fetched to say that your low back pain may actually be a pain in the foot!
Inner Unit (Trunk) Dysfunction
The Inner Unit of the trunk consists of the diaphragm, transverses abdominus, external fibers of the internal oblique, the pelvic floor, and the lumbar portions of the longisimus and iliocostalis musculature. All of these muscles operate on the same neurological reflex loop. As such, dysfunction in one basically inhibits the system as a whole. In the case of aberrant respiratory mechanics, loss of diaphragmatic excursion is often seen. This disrupts Inner Unit function and leads to loss of segmental stabilization via disrupted mechanics within the intra-abdominal pressure, thoraco-lumbar fascia gain, and hydraulic amplifier mechanisms. There are some rather simple assessment strategies for determining if someone’s Inner Unit is dysfunctional and contributing to low back pain.
Consider as well that the origin of your low back pain may not be due to a muscle, ligament, bone, or any part of the neuro-musculoskeletal system. Rather, it may in fact be an issue in an organ! To make a really long story short, any organ from diaphragm to pelvic floor can shut off the Inner Unit of the trunk (see above). This occurs through something called a viscera-somatic reflex. Basically, an organ that is stressed will decrease muscle function to muscles that are on the same “nerve channel” as that organ. So, for example, if someone has an issue with the small intestine (the “nerve channel” for the small intestine runs from the T5 to the T9 spinal segment), certain abdominal muscles will begin to behave in a dysfunctional manner. This can lead to segmental instability in the lumbar spine and low back pain.
The $64 Question
How do you figure out where your back pain is coming from? The answer is rather simple – Have a comprehensive orthopedic physical assessment performed that takes into account all of the potential factors listed above. There are many professionals within musculoskeletal and manual medicine that can help you with such an assessment. A Canadian or European trained Osteopath is a great place to start. As well, some Chiropractors, Physical Therapists, Massage/Neuromuscular Therapists, and high level C.H.E.K. Practitioners may also have experience in assessing these issues.
I have worked with clients with chronic back pain since 1999. My experience has taught me that comprehensive assessment followed by a multidisciplinary approach to correcting the threats to optimal movement is invaluable. Accurate assessment cannot be overestimated. Assess, correct, and progress the movement program based on follow-up assessment of the neuro-musculoskeletal system.
If you have questions or comments about the contents of this post, please feel free to send them to me directly or leave them in the comments section below this post.
Thank you for reading!
Suggested Reading and Study:
- Posture and Craniofacial Pain by Paul Chek (a chapter in Chiropractic Approach to Head Pain, edited by Darryl D. Curl
- Movement, Stability, and Low Back Pain by Vleeming, Mooney, et al
- WTF: What the Foot? by Gary Ward
- Cranial Osteopathy: Principles and Practice by Torsten Liem
- Orthopedic Physical Assessment by David J. Magee
- C.H.E.K. Level 3 Module /Internship with C.H.E.K. Institute Faculty
- American version of Neuromuscular Therapy for Cranio-Cervical Mandibular disorders (CCMD)