Treating Low Back Pain: Are you Treating the Symptom?

by Tim Agnew

A major complaint from clients in the field of bodywork is low back pain. Chronic lower back pain causes more disability in the workplace than any other condition and as a result, accounts for 33% of the cost of Worker’s Compensation claims. It also has been very profitable for health care. “The picture that emerges is consistent...that 70% of hospitalizations and 80 % of hospital days were inappropriate...this would represent, for a single year, almost one billion dollars in unnecessary hospital expenses alone,” said Dr. Daniel Cherkin in a new study. Hospitals are not the only ones wasting huge amounts of the patient’s money. Since the majority of people afflicted with back problems never solve the pain—or if they do, it is temporary—they learn to live with it and usually fall into the “factory syndrome” of treatment after treatment. They see chiropractors and orthopedic surgeons to no avail.

The problem, too, is that like any sort of pain, living with it adds to a reduction in quality of life. With pain, you just can’t do the things that make living so enjoyable. There are many reasons for this, but let us instead focus on treatment. While a massage therapist might have several modalities in his or her toolbox in which to treat a patient, using a modality that only treats the symptom (pain) is not in the patient’s best long-term interest. This is not to say that these types of modalities are useless; they certainly have their benefits. But a better modality is one that educates the patient on her condition during treatment, and shows the patient how to continue her treatment once she has left the therapist’s office. True healing does not take place unless the individual is motivated to comply.

Clinical Flexibility and Therapeutic Exercise (CFTE) is a protocol consisting of specific assisted flexibility and orthopedic assessment techniques designed for long-term treatment of pain. Patients are treated, educated, and usually discharged with a full understanding of what they are required to do to help their pain. Let’s examine some aspects of this modality for treatment of low back pain.
Now, we know a chiropractor’s approach is to adjust the structure, that is, to put things back into alignment by adjustments. This is all well and good, a herniated disk may need to be “helped” back into place by physical manipulation. But let’s ask this question: How did the bulging disc become dysfunctional? Muscles. Imbalance in the body leads itself to dysfunction. This means the muscles of the back—and here, because of referral pain, we may as well use this reciprocal equation for the phrase “low back”:

HIP=LOW BACK
LOW BACK=HIP

The muscles of the hip/low back may be weak (atrophy) or limited (ROM). These two possibilities give us all kinds of solutions for treatment. One of the main culprits of low back dysfunction is the psoas muscle. It originates from the anterior surfaces and lower borders of the transverse processes of L1-L5 and the bodies and disks of T12-L5. The iliacus, which, of course, is part of the psoas, originates from the upper 2/3 of the iliac fossa (ilium). The psoas attaches to the lesser trochanter on the femur. The psoas present several problems associated with low back pain. Because of its attachment along the thoracic and lumbar spine, flexion of the hip causes a pull on the disks at this attachment. (This is also known as “the psoas paradox,” where the lumbar spine is hyper-extended as the hip is flexed.) Also, the psoas will tilt the pelvis anteriorly when limited, and this puts another vector force upon the lumbar spine. This is one of the reasons why most herniated disks occur at L5-C-3,4.

A patient with a tight psoas is automatically predisposed to low back problems, so opening this tissue is important. If your patient has any history of back issues, the psoas muscle should always be stretched. Truthfully, you can penetrate the rectus abdominis with your fingers and rub some of the fibers of the psoas all day, but you will not lengthen that tissue. With the CFTE modality, a therapist would first lengthen this muscle completely, using an assisted stretch. As with any psoas stretch, the patient must be instructed to keep the rectus abdominis muscles contracted to protect the lumbar spine. If a patient complains of pain in the back during a stretch, stop and help the patient locate the abdominal muscles (by palpation or with the patient’s own hands). Remember: opening the psoas muscle will prevent disk herniations from developing and help a herniation re-set itself. The psoas should then be strengthened. As you have probably noticed so far, we have not mentioned the typical muscles massage therapists might “rub” for back pain. These muscles include the semispinalis thoracis group and the deeper tranverspinal muscles. Back pain is usually felt here, but the pain is really much deeper and almost always referred from the muscles we are discussing. This is not to say that massage for the superficial muscles will not be beneficial.

To really help low back dysfunction, we must get to the deeper muscles— including those of the hip. And this is one the powerful attributes of CFTE: a therapist can get to the deepest level of soft tissue. There are six deep eternal muscles of the hip, in this order: quadratus femoris, obturator externus, inferior gemellus, obturator internus, superior gemellus, and piriformis. They originate around the sacrum and attach on and around the greater trochanter. These muscles rotate the hip externally and allow us to walk without (hopefully) hindrance. These muscles, when limited and ischemic, freeze the hip much in the same way as frozen shoulder. The acetabular labrum is very similar in tissue density to the glenoid labrum. This tissue lines the acetabulum and helps provide stability in the hip. The ligaments that surround this tissue (iliofemoral, sacrotuberous, et al) will also become “stiff” along with the muscles. When the rotators of the hip don’t move properly and are weak, the rest of the body suffers. Most of this limited movement or weakness is transferred to the back. (There is also a wide referral pattern from the hip to the back. Sciatic pain, for example, is often felt up into the back as well as down the posterior hip.) Again, these muscle should be tested for range of motion (ROM), and if limited, completely opened using the stretch protocols. Keep in mind that in some people, these are some of the tightest muscles in the body. They are so tight that they may have changed their gait, and the patient is probably not aware of the stress he or she is placing on other parts of the body.

The gluteus maximus is also an important muscle to consider for solving back pain. This large muscle, with its origin at the external surface of the ilium and its attachment at the great trochanter, has large, fan-shaped fibers. It’s a powerful muscle that extends, laterally rotates, and abducts the hip. (The lower fibers adduct the hip.) This muscle must be opened using the gluteal stretch. Many times, simply engaging this muscle by manual resistance is enough to shift (or “absorb”) the pain. This muscle is also very weak in most people, thus providing no support for the low back and pelvis.

The biceps femoris, which is part of the hamstring group, is also a major back muscle. Its attachment, at the ischial tuberosity, means it has a direct effect on the pelvis. If the hamstrings are tight, they will pull the pelvis posteriorly, thus applying pressure on the low back. The biceps femoris’ action is extension of the hip and flexion of the knee. The fibers run vertically, so the line of pull is always “against” the pelvis.

The sacrotuberous ligament is an important ligament to remember, because it relates to the biceps femoris biomechanically. This broad, solid ligament expands between the ischial tuberosity and the edge of the sacrum. But look closer: The fibers of the biceps femoris run directly into this ligament! Will the sacrotuberous ligament be involved in loss of movement and low back pain? Absolutely. The sacrotuberous ligament must be opened along with the biceps femoris. All of this tissue can be lengthened using the assisted protocols in CFTE.

Back pain is a major dilemma for many people, yet it can be treated, many times without surgery. To help the pain and sometimes solve it, it is necessary to treat for long-term goals, and not the symptom itself. Clinical Flexibility and Therapeutic Exercise offers the massage therapist powerful tools to assist in treatment and education of the patient. It also gives many people in pain what they’ve been looking for: a way to really help themselves get better.


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