Lower Back Pain

"Individuals under 45 years of age complain more about low-back pain than any other condition. Eighty percent of the adult population will experience low-back pain at least once in their lives, and five percent of these will develop into a chronic condition. Low-back pain accounts for 25% of lost work days. "(American Council on Exercise)

There are many causes of both acute and chronic lower back pain. Correct diagnosis and early intervention are critical. Using specific orthopedic testing, postural and lifestyle assessment, the exact cause of your pain can be determined and treated.

Symptoms of acute (sudden onset) lower back pain typically include sharp pain, dull achy pain, muscle spasms and sometimes sciatica. The pain may be generalized to the whole lower back and gluteal area, or it may be specific to one spot. Sciatica is impingement of the sciatic nerve causing sharp "nerve pain" that radiates down the back of the leg and sometimes paraesthesia (numbness). The sciatic nerve can be impinged in several areas; where it exits the vertebral column (at the spine), where it exits the sacral foramina, or under the piriformis muscle (gluteal muscle). These symptoms can also indicate a herniated disk, therefore it is very important to determine the cause as soon as possible and before any treatment is recommended. Acute lower back pain can usually be linked to some recent activity like lifting a heavy object while rotating the spine, a fall, an MVA or playing high impact sports.

Symptoms of chronic lower back pain include dull, achy pain that can be unremitting or comes and goes. Chronic conditions develop from acute conditions that were never treated properly and didn't resolve. Chronic conditions are highly susceptible to becoming acute again due to re-injury. Some people's symptoms will last months, years or a lifetime if never addressed.

 

I have personally experienced acute and chronic lower back pain. I grew up in Red Deer, Alberta where we had outdoor skating rinks at all the schools in the winter. When I was in the 4th grade, so about 9 years old, my P.E. teacher (Physical Education) had our class playing Red Rover on ice skates. I was "clothes-lined" when I hit the other teams arms and slammed into the ice very hard. I severely bruised my tail bone and was knocked unconscious. For years after this incident I suffered with recurring spasms in my lower back muscles and constant aching pain. My M.D. prescribed pain killers and muscle relaxants and recommended I go for chiropractic, which helped, but never really solved the problem. I think that at the time I could have used an RMT and a physiotherapist as well.

When I was about 15 years old I started doing Pilate's on my own from a VHS tape. My motivation was entirely vain; I just wanted to look good in my bathing suite that summer. I had no idea at the time that strengthening my core muscles, stretching my back muscles and mobilizing my spine would resolve my lower back pain. Now that I'm a medical health care professional I'm astounded that this was never recommended to me by any of the practitioners I was treated by.

In a way I'm thankful that I had that experience. When patients come into my clinic and tell me about how hard it is to get through every day with the pain, I know exactly what their talking about. I've been there. I was there for nearly 7 years. I know about being restricted from doing the things you love. I know about laying in bed for days, pumped up on anti-inflammatory's and muscle relaxants. Alternating the hot water bottle with the ice pack and dreading having to get up for any reason.

Disc Herniation

Image from Wikipedia

As an RMT (Registered Massage Therapist) I treat both acute and chronic lower back pain on a daily basis. The first thing I look for is any indication that a lumbar disk may be herniated. A herniated disk is when the more viscous inner part of the disc, the nucleus pulposus, protrudes through the fibrous bands of the outer layer, the annulus fibrosus. The protrusion puts pressure on the nerves exiting the spinal chord causing pain. There are a set of specific orthopedic tests that can confirm or deny that a disk may be herniated. If I conclude that this might be the case I recommend the patient get an MRI to confirm the diagnosis. The treatment plan for a herniated disk is very different from a strain, alignment problem or overuse injury.

The next thing to check for is an alignment problem with either the hip girdle or the lumbar spine. If a joint is out of alignment, the tissue around it will tighten up and sometimes spasm. You're body is trying to protect the injured area, but it certainly doesn't feel good. Mal-alignment can be caused by an infinite number of daily activities like sitting with the legs crossed or stepping off a curb unexpectedly to lifting and twisting. Sometimes you will feel or hear a pop at the joint, and sometimes not. The pain can set in immediately or later, even up to 24 hours later.

Alignment problems can also be due to muscle imbalances. A hamstring strain can cause the injured muscle to heal in a shortened position and therefore not allow the iliac bone to move properly while walking/running/sitting/etc. Or the iliopsoas could be tight and shortened from prolonged sitting on a daily basis, pulling the lumbar spine more anteriorly.

When one or both of the sacroiliac joints (S.I. Joints) slip out of alignment it can cause muscle spasm, local and radiating pain, sciatica, etc. The S.I. Joints are located between the sacrum and iliac bones on either side of the sacrum. The iliac bones join at the pubic symphysis. These bones make up the pelvic girdle. The iliac bones and sacrum shift anteriorly and posteriorly on each other when walking, sitting or standing. When they shift too far or stick, this is called a mal-alignement. In most cases a very simple alignment correction exercise will fix this problem. RMT's use Muscle Energy Technique to manipulate the alignment of the joints of the body. This technique is a great alternative to chiropractic, as it doesn't involve any high velocity thrust and is considered to be more gentle, though just as affective. (I'm not against chiropractic as a therapy. I personally believe that it has many great uses. I'm simply saying that there are alternate ways of achieving the same result. I encourage my patients to use a combination of therapies. I have a chiropractor that I see regularly and he helps me immensely.) If the underlying alignment problem isn't addressed, it won't matter how many massages the patient has because the area will not release due to the reflexive protective tension I mentioned earlier. At the same time, if the tension in the surrounding muscles and fascia isn't released with massage and stretching, the joint can be pulled back out of alignment. At this point we would be at square one again.

My approach is to look at the body as a whole and treat it the same way. A hypothetical treatment plan for this person would include Muscle Energy Technique, Myofascial Release and Deep Tissue Techniques to the surrounding area (QL's, Erector Spinae, Lats, Glutes, Hamstrings, and possibly the Quads, Adductors and Psoas if indicated.) We would assess their posture and lifestyle, looking for specific red flags that could have lead to their present situation. Some of those might be cycling to and from work every day and sitting down at their desk without stretching and cooling down properly. This allows the muscles of the legs and low back to cool down in a shortened position, leading to muscle imbalance. I would recommend a regular treatment plan to ensure recovery is complete before discontinuing treatment of the patient.

I would also build a home-care rehab exercise program for this person. It would include stretches for the tight muscles (most likely the hamstrings, psoas and QL's), and strengthening exercises for the weak muscles (the core abdominal and back muscles). Postural retraining would also be implemented. Some patients make the mistake of not taking the exercises seriously, especially when they feel better after their treatment. They think the problem has been fixed and there's no need for the exercises. It's the biggest mistake people make and it's why they end up coming back into my office a couple months later with the exact same problem. The reason is simple and makes sense. The person's lifestyle hasn't changed and they're doing the same things that caused the problem in the first place.

The exercises are compensations for an imperfect lifestyle, which most of us have, including myself. Being an RMT is very, very hard on the body and I have to do my exercises, just like everyone else, in order to stay fit and healthy. I still have to work on maintaining my core strength, stretching my back muscles and mobilizing my spine. If I don't, all my symptoms come back. In most cases, explaining this to people is enough to make them realise they have to commit the time and effort to themselves in order to stay pain free. I always ask people to be honest with themselves about whether they are going to do the exercises or not. If not, I recommend they see a physiotherapist or athletic therapist on a regular basis and get them done there. It's a set time and place for that purpose only and it works for those people.

There are many causes of low-back pain and many options for treatment. As a patient you want to make sure your therapist addresses everything from posture and alignment to muscle imbalances and lifestyle. There's no need to suffer,  whether you have an acute injury or have had chronic pain for 20+ years. There is a reason for it and a solution.

K. Thompson, RMT