Recurrent Back Pain

Editor's note: Prior to his career in chiropractic, Dr. Harman, a graduate electrical engineer, was employed by IBM for 17 years, a number of those years in the US space program.

Have you ever had a patient whose lumbar or sacroiliac adjustments just didn't seem to hold? You adjusted them over and over. Their symptoms were temporarily relieved but returned much too soon.

Perhaps you're missing a crucial piece of the biomechanical puzzle. As wonderful as the chiropractic adjustment may be there are times when it is, as mathematicians say, necessary but not sufficient.

What I am suggesting is that the procedures used by you during your physical examination may be flawed. I am specifically referring to the standard orthopedic muscle tests for the pelvic musculature. They are not identifying underlying dysfunction that then, since it's not recognized, is not treated.

These tests seem to reveal only the most catastrophic of failures. The tests are usually negative, even on patients in such pain that they have tears streaming down their face. Have you ever wondered why patients speak of feeling weak yet their muscle tests are normal -- 5/5? Did you just assume that it was due to pain?

We have also been led to believe that diminished abdominal muscle tone is the culprit in low back pain. I suggest to you that the real cause is most frequently the piriformis, gluteus maximus, or hamstring muscles; occasionally a failing quadratus lumborum or gluteus medius.

Why, you ask, are these muscles so important? They're important because they are major spinal and pelvic stabilizers, the reason you and I are bipeds. Unfortunately the textbook definitions of these muscles list their secondary function, omitting their primary role entirely. Yes, the gluteus maximus does extend the leg for locomotion. The piriformis rotates the leg and the hamstrings flex the knee. I've yet to see a patient complaining that they can't pull their leg backward or turn their foot out. They point to their back or pelvis and complain of pain somewhere "back there."

The Peter Bachin charts of the skeleton and muscle system are excellent tools for teaching patients about body mechanics. I have them framed, glassed and hanging behind my examination table. Take a close look at the fiber direction of the gluteus maximus. It's 45 degrees. What does that suggest to you? Guy wires, of course! The gluteus maximus functions as a guy wire. The body is like a flagpole except that it isn't buried in the ground; it's hinged at the hip joint. You will note the origin of the muscle is on the ilium with its insertion on the iliotibial band near the greater trochanter, below the hip joint.

Consequently the gluteus maximus is responsible, in its primary function, for extension of the trunk into its normal vertical position. This function is so critical that if your gluteus maximus muscles were injected with curare, temporarily paralyzing them, you'd fold up like a leaf with your eyebrows assuming a position in close proximity to your shoe laces.

The piriformis is a rotator of the leg but also functions as a guy wire, similar to the gluteus maximus. The hamstrings flex the knee, but primarily stabilize the inferior portion of the pelvis.

Aside from the failure of orthopedic testing to identify dysfunctional muscles, confusion also results from where the patient reports the symptoms. One Monday morning my first five patients all complained of "low back pain." The first patient reported pain at the right sacroiliac joint, the next at the left sacroiliac joint; another reported feeling central pain over the sacrum. The fourth patient complained of a "belt of pain" across her back; the fifth described it as a "band of pain" in the left erector spinae muscles extending up to about T9.

The cause was failure of the right gluteus maximus and piriformis muscles in all five patients. (One patient also had a hamstring failure.) Of interest is that the lady with left sacroiliac pain had undergone conventional medical care for her condition for about nine months. She first received a fairly typical course of medications, including analgesics, muscle relaxants, and NSAIDS. Medications were changed several times in the search for a drug or combination of drugs that would solve her problem. Her left sacroiliac joint was injected twice with steroids without relief. Eventually she was sent out for physical therapy. Over a number of months she received heat, cold, massage, high voltage galvanic stimulation, ultrasound, and both passive and active exercise. The treatment was unsuccessful, the patient dismissed with the frequently heard admonition that she would "have to learn to live with it."

This patient was quite upset when I began treating her right gluteus maximus muscle and piriformis. She reared up on the table and castigated me for not listening to her. She practically screamed at me, "My problem is on the left side!" I quickly recovered my composure and settled down to explaining why I was treating the right side. "Your problem," I explained, "is on the right side. Your symptoms are on the left side." While this was a difficult concept for her, she was quite pleased with her progress over the next two weeks after nearly a year of suffering.

This is a difficult concept for many patients to understand because their knowledge of muscle function is limited to muscle spasm, disuse atrophy, and overt weakness. In my experience symptoms are expressed at the body's weak points and, in some cases, may coincide with the side of muscle dysfunction.

The ligaments of the sacroiliac joint, like other parts of the body, are not symmetrical: the left are different from the right from the moment of their creation. Consider all of those falls while learning to walk, ride a tricycle, a bicycle, falls from apple trees, ponies, skateboards, etc. A series of micro-traumas (probably some major ones, too) accumulates in the body. Scar tissue is good; it keeps the body from falling apart but is not nearly as flexible, strong, or resilient as the original.

Now that we have a basis for understanding the underlying problem, let's talk about the solution. It's a two-step process: analysis and treatment.

Analysis

I still utilize the standard orthopedic and neurologic tests during my physical examination if the patient can tolerate them. After they have yielded their usual negative results, I perform the following tests with the patient prone on my adjusting table as a part of treatment. (I usually perform them after making all necessary and indicated adjustments but the muscles may be analyzed and corrected before manipulation. In some cases correcting the muscles first may be desirable.)

My practice is 100 percent based on the Activator technique. After making all necessary spinal, pelvic, and extremity adjustments, I then begin testing the muscles in the following manner. (Leg length should be equal at this point.) For convenience I will describe testing the patient's right side with the doctor standing on the right side, about mid-thigh.

To test the piriformis: Flex the knee to 90 degrees with the patient prone. Then rotate the lower leg to the midline of the body, relaxing the piriformis. Place your right middle finger at the origin of the piriformis and your thumb at the insertion on the greater trochanter. Press in firmly since this muscle is under the gluteus maximus. Instruct the patient to hold the leg in that position. With your left hand grasp the leg near the ankle and pull toward you for two to three seconds while the patient resists. If the muscle is functioning normally, you will feel a kind of "lock" and the patient will easily resist you.

If a muscle is dysfunctional the patient will be "efforting," perhaps rolling or torquing the whole torso, and the muscle may have a "soft or mushy" feeling. This is more commonly seen in a dysfunctional gluteus maximus. An additional clue is that instead of the pressure of the leg being felt in your fingers, you will feel pressure at the web of your thumb and forefinger. The body already knows the piriformis is weak so it adapts. It contracts the quadriceps femoris, producing a diagonal motion in conjunction with the piriformis that approximates the lateral resistance you are looking for. These clues are valuable, but the heart of the test is noted when returning the leg to the table. If the muscle is dysfunctional, the right leg will lengthen compared to the left. The body is saying to you, "Please fix this." Where the dysfunction is minimal, it may be instructive to test the good side so that both you and the patient know how normal feels, but the crux of the test is the change in leg length.

[The reflex leg change from the testing typically lasts for several seconds. To reduce test time, lightly stroke the calf of the shorter leg toward the foot to reset the leg lengths to equal again before testing the next muscle.]

To test the gluteus maximus: Flex the knee to 90 degrees to make it easier for the patient to lift their leg. I instruct them to raise their leg and usually assist them in doing so, particularly at first when they are in pain. Then I remove my left hand from their ankle and using both hands, I squeeze the gluteus maximus muscle. Because this is a rather broad muscle, I squeeze it in several places throughout the belly of the muscle. Return the leg to the table and check for a leg lengthening. As above, if it lengthens it is in need of treatment. (In the acute phase, the patient may be in too much pain for this test, if so, just goad the muscle with your fingers.)

To test the hamstring: Flex the knee about 30 degrees. Goad the origin of the muscle at the ischium with your right fingers while gripping both sides of the knee with your left hand to irritate both insertions. I usually use my left elbow (contacting the patient's heel) to apply downward pressure to the leg and consequent tension to the muscle. The patient should be resisting. A lengthening of the right leg means the muscle needs treatment.

Although they are seldom a problem, I test the gluteus medius and quadratus lumborum by just squeezing them with firm pressure and then checking for a leg length change. The tensor fasciae latae and the latissimus dorsi can be tested the same way but are only involved in a small percentage of cases.

How do you decide which side to test first? Simple: whatever side you are standing on at the time. I have found no reliable correlation between the dysfunctional side and the symptom location. If the first side tested is negative, then test the other side. (I do note a preponderance of right-sided failures that do not seem to be related to the dominant hand or what Activator practitioners call the PD side.)

Keep in mind that although this testing procedure takes less than 60 seconds per side once you have practiced it; the data is invaluable. After the failure pattern has been established, you test just those muscles in the future. The exception to this is in the first few treatments or after a new injury. Occasionally an additional muscle failure will be found after a few visits. My impression is that the body is trying so hard to adapt that it is unable to signal for help at first until some improvement takes place from treatment.

I have seldom found dysfunction on both sides. These have usually been immediately after trauma or when the condition has existed for so long that the other side is forced into dysfunction from trying to handle the load. At that time treatment on both sides is necessary, but only for a time or two.

In a few very rare cases, I have seen the side of the dysfunction change over time. However, there has usually been some new trauma.

When I first began treating muscle dysfunction, I stopped testing and treating as soon as the muscles tested clear or negative. What I noticed was that a fairly high percentage of patients came back on a future visit complaining of the return of the same pain. When the muscles were retested, they were found to be dysfunctional again. My current criterion is that I do not consider them under control until they test clear for three consecutive visits. I explain to patients that they may not be cured, only under control for the time being. Early relapses are possible, particularly if they slip or suffer a strain similar to whatever set off the problem in the first place. They seldom have any memory of the initial or causative event.

When they test clear or negative on three consecutive visits, they will usually remain so. However, I have seen them relapse weeks or months later. My hypothesis is that they have some amount of permanent damage or weakness. Given the right set of circumstances, the problem can be reactivated. I have even seen a few cases where it appeared that a particularly stressful event, such as divorce or death, set off the symptoms again. By this time most patients have a better sense of how their body should feel and come back in stating they don't "feel quite right." Usually a few treatments will normalize them again after a relapse.

Treatment

Any microcurrent unit will do. The settings I use are .3 Hz at 600 microamps for 20 seconds. I normally treat directly through the patient's clothes, saving the time and expense (and sometimes embarrassment) of gowning the patient. Some hard woven wool or polyester clothing resist wetting, necessitating patient gowning. Be cautious of silk fabrics: some will water spot. To help penetrate clothing, I add a few drops of Kodak photograph wetting agent to my water container.

Biphasic current will work and is all that some devices offer. I have found that the proper use of polarity, following Becker's conventions of polarity in the body, produces better results. The positive probe should be placed nearer to the midline of the body and/or more superior to the negative probe.

In treating the piriformis, place the probes in the same positions as the finger placement during testing, the positive probe at the sacral origin.

I start treatment on the gluteus maximus by pulling out the patient's shirt or blouse from their pants or skirt. This allows me to sweep the positive probe across the origin of the gluteus maximus. This is more easily accomplished by using the longer TMJ probe. The other probe is placed at the insertion of the muscle near the greater trochanter.

In treating the hamstrings, the positive probe is placed at the ischium with the negative probe at the medial attachment near the knee. Perform the same treatment on the lateral attachment.

The meter allows you to monitor the progress of treatment. If the meter stays high after the end of the treatment cycle, then treatment can move to a new area. Otherwise continue through another treatment cycle (or more as necessary) or rewet your probes. Clothing may be soaking the water away, causing lack of good contact. If the area becomes too dry and the current becomes concentrated, the patient may feel an unpleasant pricking sensation. (If you cannot get the meter to stay high, try another area of the body on bare skin. If they don't charge, they may be too dehydrated and need to be hydrated for the treatment to be optimally effective.)

In all cases, after treating the muscles from end to end (origin to insertion), then treat from side to side through the belly of the muscle, about every inch down its length.

Hypothesis

My hypothesis on muscle dysfunction is that we are dealing with damage or derangement of the Golgi tendon organs and the muscle spindle cells. They are not sending the proper information to the brain. Consequently, the information sent back to the muscles is incorrect, resulting in improper settings of muscle tone. That is the rational for the probe placement. First treat the muscle(s) from origin to insertion to include the Golgi tendon organs; then treat from side to side to pick up the muscle spindle cells that are more widely distributed in the muscle belly.

Caution

Patients will frequently leave your office and talk with their friends about their muscle dysfunction. This is usually interpreted by the patient and their friends as a muscle weakness. The aware patient may note a feeling of weakness, particularly if after identifying a failure you go to the other side and test. The problem is their friend will advise them that they do not need a chiropractor, but a workout at their gym. They'll usually throw in a free two week trial.

Before the patient leaves your office, you must address this problem. The weakness a patient may notice is not due to muscle atrophy. I suggest the term dysfunctional muscle. If the patient currently is in some kind of gym or workout program, I usually ask that they put the program on hold temporarily until their muscles start to respond. My experience is that if they continue their workout they appear to "reprogram" in the old problem, reducing or destroying the progress made to that point.

General Comments

Treatment frequency is usually three times per week initially. In especially acute cases I have treated daily for the first week. As the muscles improve, I extend the time between visits. If the time between visits is too long the patient may lose the benefit of the treatment between visits, starting all over again at each visit.

Patients always want to know how much treatment is required. My answer is that I do not know initially, but may be able to make a more realistic estimate after a few visits. If the failure is of recent origin, only a few visits may be required to return the muscles to normal. If the problem is old and chronic, 10-40 treatments may be needed. One example of that length of care was a patient who was a broad jumper in high school, before the days of foam or air bags to land on. He injured the muscles in the takeoff or landing. However, the symptoms didn't set in until he was about 30. His back pain became worse, and by the time I saw him at age 42, he was nearly disabled.

His failures were in the right gluteus maximus, piriformis, and hamstrings. As he improved, the gluteus maximus and piriformis stabilized first. The hamstrings needed treatment for a longer time. As the treatment progressed, the meter readings confirmed that the most seriously injured part of the hamstring was the upper third. Today he is back at work and no longer suffering the nearly paralyzing pain that plagued him for so long. He no longer considers taking an early medical retirement and has returned to playing golf.

I credit the above techniques of diagnosis and treatment to Dr. Ward Lamb of Nevada City, formerly a treating doctor in San Jose for many years. What I have done is to work with them and pass them on to our profession because patients deserve the best and most complete care they can get. I consider it nearly criminal to send a patient out the door without correcting an underlying problem.

R. Dean Harman, DC
San Mateo CA 94402
Phone: (415)-571-1122
Fax: (415)-571-1122
E-mail: RdeanH@aol.com