14 low back pain, a cumulative-trauma disorder low back pain … · 2018. 10. 9. · 14 2/14/2004...

14 2/14/2004 Low Back Pain, a Cumulative-Trauma Disorder ©2004, John S. Gillick

www.DrGillick.com 1 Low Back Pain Puzzle

Low Back Pain Puzzle Diagnosis and Causation

Back pain is a symptom, not a diagnosis. The clinical condition of low back pain

usually comes from muscle and ligament spasm-strain or nerve pinching. Ongoing back pain is a cumulative trauma condition, with multiple contributing factors. Structural, postural, and behavioral dysfunctions precipitate, and then perpetuate, the pain production.

Management of back pain is best directed at: (a) diagnosis (identification of the

dysfunctional muscle or nerve groups that are producing the pain); (b) removing the causations (the conditions or behaviors that precipitate or perpetuate the dysfunctions); (c) restoring the dysfunctional muscles and nerves normal function; and, (d) temporary analgesia as needed to alleviate discomfort during the process. Diagnosis and identification of causes make up the cornerstone of low back pain management.

Whenever back pain is investigated, there are twelve factors -- five specific diagnoses and seven

behavioral and postural contributors -- that deserve particular attention. The specific diagnoses often co-exist and are additive with more generic simple muscle pulls. The seven behavioral and postural contributors rarely occur alone. They inevitably persist in multiples. Those seven are the unseen key contributors to the cumulative trauma causes that provoke 90% of chronic low back pain symptoms. This paper elucidates, details, and simplifies those twelve factors.

Clinical suspicion and physical examination investigation into each of these twelve factors should be a requisite start for evaluation of low back pain for every primary health care provider. Radiography, other diagnostics studies, and specialists are infrequently indicated and play a limited and very specific role.

Two solid structure disruptions, spinal disc and bone disruptions are

primary culprits in 1% to 5% of chronic low back pain. They may contribute to the soft-tissue cumulative trauma symptoms in up to ten percent.

Soft tissue disruptions caused by muscle and ligamentous strain account for ninety-five percent of low back pain symptoms. Half of the soft-tissue pain generators are from fatigue and strain of the major balance muscles of the back (quadratus lumborum, ilio-costalis, gluteals, etc.).

Three specific soft tissue dysfunctions -- musculo-ligamentous strain conditions, ilio-psoas strain, facet joint strain, and sacroiliac joint strain, account for the other half of soft tissue induced disabling low back pain. The pain with of these is usually episodic while the onset is often sudden or jolting trauma. The pain is from chronic muscle-ligamentous-myofascial cramping and fatigue.

Seven contributors are the principal cumulative trauma components in 90% of

back pain syndromes. The seven, four behaviors (1- carriage of wallet in the back pocket; 2 -uncorrected loss of foot arch height; 3 -strained sleep position; and, 4- driving a stick-shift vehicle) and three postural asymmetries (1- short-arm length, long- waisted; 2- leg-length difference; and, 3- short hemi-pelvis) are as prevalent as to seem benign and as to be transparent or invisible.

These seven dominant contributors may act as primary or secondary back pain causes. They and perpetuate and sustain the soft tissue dysfunctions, and they contribute to the solid structure disruptions that underlie chronic low back pain.



Solid-structure injury/ dysfunction The solid-structure injuries/dysfunctions, particularly intervertebral disc disruption, may play a role

(participation or, even, triggering) in up to fifteen percent of all low back pain syndromes. They may be the primary (and occasionally, the sole) cause in 2 to 5% of low back pain conditions. These have been credited as being co-contributing factors (additive to the cumulative-trauma) in up to 15% of low back pain. Surgery may be useful for the structural injuries but is indicated in less than one percent of overall back pain sufferers. Of those with definite radiographic indication for surgery, cure or improvement with surgery is 70% = 0.7% of the overall population. Surgical success for those with �“soft�” indications is optimistically less than 30%. Solid-structure injuries/ dysfunctions may play only a short-lived role as the trigger that initiates a cascade of soft-tissue strains that must then be controlled before the resolution of a back pain syndrome is accomplished.

Because they may be surgically approachable and progressive damage may occur, the structural injuries should always be a part of the equation in diagnostic considerations, especially whenever the causation/ diagnosis of low back pain are unclear. However, since these two conditions are widely discussed and familiar to most, they will not be elaborated upon here.

The Solid Structure Two This is the subject of the rest of medical literature. These are the �“other�” 1 % to 5 % about which most physicians have had most training.

Specific nerve-cord pressure S-1 Solid-structure Two This includes true, specific disc rupture, true nerve pinching with specific radiculopathy,

intra-spinous pressure from tumor, infection, etc. The caudae equinae syndrome is in this category.

Structural instability/ damage S-2 Solid-structure Two This includes true, specific bony structural disruption, traumatic, proliferative, neoplastic,

metastatic, infectious and congenital conditions. This includes osteoporotic or traumatic compression fractures, �“slipped vertebrae�”, etc.

The Jolting �– Episodic Three: (J-1 through J-3)) Episodic trauma (3) -acute, recurrent. These are specific strains. They are episodic but may become chronic. Specific body characteristics predispose to their occurrence and their recurrence. They will often follow mechanical trauma.

�• Ilio-psoas muscle strain J-1 Jolting-episodic trauma �• Facet (esp. thoracic) dysfunction J-2 Jolting-episodic trauma �• SI joint strain/ (dysfunction) J-3 Jolting-episodic trauma

Ilio-psoas muscle strain (J-1) The Ilio-psoas (I-P) is�– a powerful major muscle of the back that originates on the �“inside�” of the rib cage, trunk and pelvis. It attaches to the lesser trochanter inside of the leg. I-P strain makes standing up painful in the abdomen, back and groin. This strain can cause one-sided diffuse back pain and/or groin or anterior thigh pain. Ilio-psoas sprain may radiate into the lower abdomen and/or the genetalia. The I-P muscle is the sit-up muscle. The trigger is usually sudden pull �– like lifting with a shovel, a quick jerking catch-movement, or straining against a seat belt. The real muscle spasm pain comes on the next morning

Ilio-psoas injury can mimic a multitude of classical, yet atypical pseudo-radicular symptoms. All of the lumbar nerve roots exit the spinal cord and pass between the I-P fibers. The femoral nerve, genito-femoral and lateral femoral cutaneous nerve fibers lie on the muscle under the ilio-inguinal ligament, where they may be trapped causing nerve compression symptoms. I-P strain frequently presents as a groin pull with accompanying back pain.



�“My whole leg went numb and weak for a few minutes (hours),�” is a key hint to diagnosis. The muscle strain may also sometimes only present as a groin strain.

Accurate diagnosis is the most important step toward recovery. Appropriate physical medicine aids recovery, along with sit and sleep position modifications. The leg on the offending side needs to be extended at night. Sitting is best done with the knee on the injured side below the level of the pelvis. Interestingly, ilio-psoas strains are usually associated with an ipsilateral short hemi-pelvis. This huge and nebulous muscle is the reason for the success of McKenzie extension exercises.

Facet (thoracic, lumbar, cervical) dysfunction (J-2) Thoracic dysfunction (�“thoracic strain�”; �“thoracic (rib) subluxation�”) is one of the most common injuries seen in an occupational medicine practice. Lumbar facet dysfunctions are less frequent but account for about 15% of acute back strains (half as common as ilio-psoas-strains, but quicker to resolve and less likely to become chronic).

All of the vertebrae from C-3 through L-5 articulate with a pair of superior and inferior facet joints. The thoracic vertebral also have to stabilize each rib with three extra facet joints. Thoracic facet dysfunctions (strains) are the most frequent, simply because the rib junctures are the most vulnerable to torque �– particularly in individuals with positional (compensatory) scoliosis. These dysfunctions recur at the same levels.

The onset of facet joint pain is sudden, usually associated with a jerking motion that results in painful. The inciting incidents for facet strain recurrences are �‘just the wrong tweak or movement�’ (onset during sleep is common) and often do not require much force at all. Facet joints can �“freeze-up�” suddenly �– a musculo-ligamentous lock-up �– and become more painful when kept immobile past 12 to 24 hours.

Facet dysfunctions (strains) of the thoracic vertebrae occur most frequently since they have three extra facet joints for each rib are particularly vulnerable to torque �– particularly in individuals with positional (compensatory) scoliosis. Onset is usually with an upward outreaching of the arm, with an upper-torso jerking motion, or at night in a stomach-sleeper or twisted side-sleeper.

Despite acute �“rib joint dysfunction/ disruption,�” x-rays of the facet and rib joints are almost always read by radiologists as normal. Recurring strains may produce some joint arthritis or cause a bone scam may to be positive. Pain comes from muscle spasms around the proximal rib (costo-vertebral) joints. The pain is usually accompanied by tenderness (and swelling) at the facet joint and radiates along the costal nerve distribution level.



Diagnosis is made and confirmed clinically by physical examination matched with history. A thoracic facet dysfunction can be confirmed by a painful costochondral joint with the same rib. (The costo-chondral disruption is often the more painful site. This accounts for most chronic and recurring idiopathic �“costo-chondritis.�”). Local muscles are also in spasm and are the frequent cause for radiculoid pain into the neck, chest, arms, and lower torso.

Early facet joint mobilization speeds recovery, and may be the initial treatment of choice. Hippocrates (400 BC) practiced and wrote on manual medicine for this condition, as did Galen (190 AD). The �“bone-setters�” practiced the skill during the Middle Ages. Treatment by manual medicine (joint as well as soft-tissue manipulation) is the most useful. Early (within 8-14 hr) can frequently �“cure�” the episode. The longer one waits to initiate manual treatment �– the slower the response. Facet disruption usually resolves with bed rest ad muscle relaxation over days to months. It can become chronically disabling. A large number of people �“self-manipulate�” or �“crack their ribs�” for effective treatment. There is a large section in folk medicine on this condition.

Manual therapy for facet dysfunctions is the bread and butter of the chiropractor and manipulating osteopaths. Unfortunately, a minority of those practitioners does not teach postural and behavioral preventive skills or over-manipulate the joints over prolonged periods of time which accelerates facet joint degeneration. Facet dysfunctions (thoracic, lumbar, cervical) are more common in those with anatomical or behavioral predispositions: scoliosis, fixed or adaptive scoliosis, short leg, short hemi-pelvis, long-waisted, effective short-hemi-pelvis, wallet in back pocket, stick shift driving with use of clutch and shift-leaver. After an initial facet-disruption episode, recurrences at the same joint can often be anticipated SI joint strain (dysfunction) (J-3) S-I joint strain/ dysfunction usually comes on abruptly causing the pelvic muscles to go into spasm and make standing straight, sitting and even walking very painful and difficult. With acute S-I dysfunction pain is felt into the buttock, hip and low back. Typical causes for S-I joint strain are a fall onto the buttock, a sudden pelvic twist, or a hip-slide up onto or off of a raised seat, such as in a raised truck or SUV bucket seat edge.

S-I strain also occurs more frequent in those with unequal leg lengths or a short hemi-pelvis. It occurs more on the long-leg side. X-rays don�’t show S-I joint displacement. These are very similar to facet joints. The spasm or pain may shift to the other side for some curious reason. The FABER and Patrick�’s tests help in diagnosis.

Manipulative adjustment within the first 24 hours of a sudden-onset dysfunction may stop the process. Otherwise, recovery from S-I joint strain is often slow and frustrating. Lower body posture-balance is important in recovery and maintenance �– feet-arches, leg length, sitting balance. Physical therapy, chiropractic or other manual medicine, with emphasis on the pelvic muscles and adductors, play a useful role in treatment & recovery.

Seven modifiable characteristics: There are four behavioral/ acquired characteristics and three anatomical imbalances that play a crucial role in precipitation, aggravation and maintenance of musculo-skeletal and myofascial pain syndromes. These are here classified as the Behavioral Four and the Postural (Anatomical) Three.

Travell maneuver to relieve acute SI joint problem

Hippocrates 400 BC; Galen 190 AD

16th Century Bonesetter



T

Small Business Success Volume 13, May 2000 -- pages 18-20

Yearly publication of the Small Business Association The Behavioral Four



The Behavioral Four The Behavioral Four are behaviors and conditions that frequently produce pseudo-radiculopathies. They play pivotal roles in diffuse myofascial pain disorders and fibromyalgia. Separate, more focused articles on foot-arch and on sleep-position are posted on the www.Simple-Ergonomics.com web site.

The Anatomical Three: (A-1 A-3) Anatomical variations or idiosyncrasies These are usually from underlying anatomical variations that are congenital. Yet, occasionally they may be acquired from injury or deterioration, may be unintentional from behavioral quirks, or may be situational from improper ergonomic circumstances. Off-setting the anatomical imbalances require identification, followed by thoughtful ergonomic adaptation or accommodation. The early injuries brought on by these conditions are soft tissue disruptions; while permanent structural changes may result from long-standing uncorrected anatomical variations.

�• Leg length difference A-1 Anatomical Three �• Short hemi-pelvis A-2 Anatomical Three �• Short upper arm length A-3 Anatomical Three

Leg length difference: (A-1) At least 70% of people have a functional difference

(greater than 5 mm.) in effective leg-length (with hemi-pelvis). Muscle fatigue, with resultant hip, back, torso and neck pain, occurs 50% more frequently in those with a net leg length differences of 0.5 to 2.0+ cm.

The quadratus lumborum (the major balance muscle of the back) is almost always involved, but the hip, torso and upper back muscles are usually also strained. Individuals with > 1-cm uncorrected differences have a sharp increased incidence of chronic back pain as well as resulting structural bone/joint damage. Uncorrected leg-length differences induce a compensatory scoliosis with standing. The condition often co-exists with a short hemi-pelvis, which further aggravates the condition. Unequal leg lengths with compensatory �“S�” & �“C�” scoliosis strain the entire spine, the legs, knees, and hips. Correction is often indicated. Correction is as simple as taping a pad under the heel of a full-time arch support.

Short hemi-pelvis (A-2) The spine of a person with a short hemi-pelvis takes off at a non-vertical angle during both sitting and standing. That spinal twist must be countered with reverse twisting so that the head can be balanced over the middle of the pelvis. A compensatory �“S�” or �“C�” scoliosis is therefore present during both sitting and standing.

To balance a twisted, scoliotic position requires ongoing combined static contractions of the back, hip, abdominal and torso muscles (quadratus lumborum, ileo-costalis, serratus, rhomboids and others). This fatigues the balance muscles.



Prolonged static (isometric) muscle activity, as with

prolonged sitting or driving, results in fatigue, with strain and pain. While the lower back-torso muscles strain to keep upright posture, the upper back and neck muscles are counter-strained. Hip, low back, mid back, upper back, neck and shoulder pains are all varying parts of the condition

A short hemi-pelvis often co-exists with unequal leg lengths. The foot on the short-leg or short-hemi-pelvis side may be a size smaller also. (Look for asymmetrical shoe sizes and pant legs)

With sitting, one shoulder may be noticeably lower than the other; or the individual will always lean onto the same elbow. Sitting on a sweater, folded towel or book relieves the strain and removes the compensatory scoliosis. Uncorrected, the condition leads to recurrent low back pains, headaches and neck aches and recurring thoracic, cervical and lumbar facet dysfunctions (strains).

Short upper arm length (A-3) (Long-waisted persons)

Persons with a relative short upper-arm length in proportion to waist length (long-waisted) experience low back, as well as, neck and shoulder pain. This occurs because the shoulders, arms, and entire upper body are being directly supported only through the spinal column and by the trapezius (the coat hanger) and levator scapulae muscles. Neck, upper back, and low back spasms result. Prolonged sitting or driving aggravates the condition. The long-waisted individual frequently squirms in a chair �– just can�’t sit still. The only comfortable sitting position may be curled up or leaning on an elbow.

Being long-waisted or short-armed is relatively common. Much seating does not provide effective arm support. The standard American chair fixed-arm height, at 8½ inches, is correct for only about 50% of the population.

Back and neck pain from the short upper-arm condition may occur when: (1) body proportions make an individual�’s elbow height greater than 8 ½ inches above seat level (office, car, home, airplane, work-station); (2) there are no arm supports (or ill-fitting or unused) during prolonged periods of sitting (car, chair, bench); (3) chair arms are wide-spread making the outward reach to the support effectively raise the elbows and make the supports ineffectual. Fixing this condition requires attention to ergonomic conditions in all settings --office, home, car, etc. A willingness to change equipment or make behavioral modifications is necessary.

Trapezius muscle and trigger areas/ pain distribution

Pain distribution with pelvic twisting



Arm and elbow support are required on both sides for proper balance during sitting. A person can accomplish this by using pads or bolsters on armchairs and on car arm supports. Bolsters, pillows, or a large handbag, may work with couches and other seating where there are no other forearm rests.

Like all the other �“idiopathic�” causes for low back problems, this condition also requires the person with the problem to accept the responsibility for correction and recovery.

C O M M E N T S The simplest, most effective and most economical approach to management of low back pain is:

First--early identification of all contributing causations �– by history, observation and physical examination; Second-- modification of all disruptive behavioral and mechanical balance factors; Third�—medication and physical modalities; and, Fourth�—indicated radiographic studies. Role of radiographic studies: Ordering an x-ray has a vital role in demonstrating to the individual that the practitioner takes them seriously. It is simply expected by many patients. Although virtually all of the literature documents that there is little correlation between �“pain�” and the x-ray findings, there is some value to radiographic diagnostics in the solid structure two. It assists diagnosis in life-limb threatening circumstances: however, its practical value is for guidance of surgery when that is a real consideration. MRI helps guide surgery and helps with obscure diagnoses �– it is not an indicated first line modality. Bone scans, CT scans and flexion-extension plain x-rays are the most useful diagnostic radiographic techniques. Unfortunately, they are the least employed. The finding of �“bulging discs,�” desiccation, Smorll�’s nodes, etc. only confuse the picture. �“Musculo-ligamentous/ myofascial strain-sprain�”: Soft tissue injury/ dysfunction

The addressed specific musculo-ligamentous strains and the musculo-myofascial fatigue of the major balance muscles account for the vast majority of low back pain categorized as �“idiopathic.�” Management should concentrate on identification and removal of causation. Treatment with pills, diet, and manual medicine acts as a bridge to give temporary relief. Removal of causation �– (which occasionally includes specifically indicated surgery), protects against recurrence and future permanent structural damage. The identified behavioral and anatomical characteristics frequently play a silent, key role in masking or slowing recovery from conventional medical treatments for back pain. Successful management requires physician knowledge and communication, along with patient understanding, acceptance, responsibility and behavioral modification. Comments about treatments and maintenance, exercise, nutrition: Physical conditioning and basic nutrition can be great value in a regular program that includes well thought out nutrition, exercise, stretching and some maintenance physical-manual massage or medicine.

Yoga, Pilate�’s, low-impact aerobics, weight training, cross training, swimming �… all play a significant role in maintenance. A healthy, properly nourished, fit and balanced body is incredibly more resistant to injury and recovers much faster from injury. However, none of these is a substitute for understanding and reversing the simple daily behaviors and mis-alignments that play such a great role in chronic pain conditions.

First is diagnosis; second is removal of causation. After that, strengthening, stretching and generalized nutrition become a part of generalized health maintenance and decreased vulnerability to injury and disease.

Illustrations from: Simons, Travell & Simons: Myofascial Pain and Dysfunction: The Trigger Point Manual;

Vol. I- Upper Half of Body; Second Edition �– Williams&Wilkins: 1999 Travell & Simons: Myofascial Pain and Dysfunction: The Trigger Point Manual;

Vol. II- Lower Extremities, First Edition �– Williams&Wilkins: 1992 Netter: Atlas of Human Anatomy, Second Edition �– Novartis: 1997



Low back pain as a Phenomenon

A Cumulative Trauma Condition -12- Twelve Considerations

-5- SPECIFIC DIAGNOSES/ STRAINS

-2 Structure Pathology (+/- 5%)

Specific nerve-cord pressure (disc, stenosis) Structural instability/damage (spondy-, compression)

-3 Jolting �– episodic -may become chronic (45%-)

Ilio-psoas muscle strain Facet (thoracic, lumbar ,cervical) dysfunction SI joint strain (facet-like)/ dysfunction

POSTURAL AXIAL MUSCLE DISRUPTIONS CONSTITUTE APPROPRIATE DIAGNOSIS OF GENERIC: LOW BACK MUSCLE STRAIN-SPRAIN�– (45%-)

CONTRIBUTING MUSCLE GROUPS AS PRIMARY OR ADDATIVE CAUSATION: Quadratus lumborum, ileo-costalis, para-vertebrals, pyriformis, gluteals, trapezius, levator scapulae, para-spinous, serratus anterior& posterior, etc

-7- POSTURAL CAUSATION FACTORS �–for- THE COMMON MUSCLE STRAINS THAT (Play a role in at least 90% of all low back pain)

-4 Behaviors / Mechanics

Sleep position Loss of arch height Wallet in the back pocket Stick-shift vehicle

-3 Anatomical Asymmetries

Short upper-arm length Leg length difference Short hemi-pelvis



The contents of this informational handout are the well-considered opinions of the author at the time of their writing. The author(s) have no treating relationship what-so-ever with reader. Professional advice should be sought from your personal health care provider(s). Neither the author(s), nor the site, have any financial interest or connection with any referenced resources or sites.

These communications are general. They in no way represent any professional

recommendations for treatment. There is no treating relationship between this author and the reader, nor is any intended. This is for educational purposes. Medical care should be directed by a knowledgeable health care professional.

This author neither endorses nor has any relationship with any product or pharmacologic agent mentioned. Any comments are his current thoughts, based upon his current knowledge and opinions. These are always quite subject to revision or change.

Behavioral modifications toward sensible and non-injurious activities of daily living should be dictated by what makes sense and is sensible.

jsgillick

14 low back pain, a cumulative-trauma disorder low back pain … · 2018. 10. 9. · 14 2/14/2004...

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