When I first started chiropractic school back in the late '70s, a new and profound concept about stress and illness was becoming popular. Dr. Hans Selye noted that the body had a typical response to stress, and that sick people all looked alike and had similar problems and similar hormonal responses to illness and stress.
I have noticed something similar about lower back pain. Lower back pain patients often look similar and often have responded in a patterned way to lower back pain. Now, this does not mean we should not tease out the differences between these patients, and tune our treatment to the patient. It does mean we should look at the similarities as well. It does mean we should have a checklist of common problems that are likely to show up in most lower backs.
What are the common threads? The lower back is inherently unstable when in pain. No matter what the original cause of the lower back pain, the deep core gets inhibited; the more superficial muscles become tight and hypertonic. If you deeply understand this muscular pattern, you will understand how to treat your patients' complaints. How does this pattern affect the various elements that affect the lower back?
Effects on the Thoracolumbar Junction
The thoracolumbar (T-L) junction gets tight. The long erector spinae attach here, these strap muscles get very tight. This can cause lower back problems in at least three ways. First, the joints of this area get restricted, and this can irritate the superior cluneal nerves, which are the superficial peripheral nerve supply to the flank of the lower back and to the gluteal area.1 I wrote about this at length recently, and it is a profound and clinically significant idea. Some concepts stick, some fall by the wayside. This one, checking the T-L junction and the Maigne tender point on the glutes, is clinically significant. Check the thoracolumbar joints on all of your lower back patients.
Second, when the long erector spinae muscles get too tight, how does this affect the lumbar spine and facet joints? One major possibility, if the tightness is combined with abdominal muscle weakness, is that the patient will have an excessive lumbar lordosis, often with the pelvis anteriorly tilted. You've seen this; it is a lazy, or hang on the ligaments, posture. This will compress the lumbar facets and can obviously irritate them. This is a classic male pattern, but can exist in females also.
Third, if the T-L junction is too tight, the lumbar spine will tend to move more, potentially creating irritation of the discs or facets. This theme is somewhat universal. One area gets tight and hypomobile; another gets inhibited and hypermobile. The T-L junction is tight, and the lumbar spine is hypermobile and easily irritated.
Effects on the SI
The multifidi, which go from the sacrum up by one or two segments to the lumbar spine, get inhibited. The multifidi are both stabilizers and extensors, so their inhibition allows lumbar flexion more easily. This obviously could contribute to disc issues, but can also affect the SI.
The sacroiliac joint's closed-pack, stable position is posteriorly rotated. The lax, easier-to-sublux position is anteriorly rotated. So, the weak multifidi allow the lumbar spine to flex and the sacral base to counternutate (sacral base going posterior). The hypertonic lumbar erectors start from the iliac crest, so they are pulling the ilium anterior. This can create the perfect storm and allow for an anterior superior ilium relative to the sacrum; an inherently unstable position.
Effects on the Lumbar Discs
What about the lumbar discs? When the deepest of the muscles that surround the spine are inhibited and have timing delays, this inherently allows too much motion in the lumbar segments. Think of the multifidi and the psoas, both of which tie directly into the discs and bodies of the vertebrae. Too much motion makes for an unhappy disc, especially one that is already injured or torn. The muscles that stabilize the disc are designed to fire, to activate, 50 milliseconds before the larger muscles activate, thus protecting the disc from aberrant motion. This function is lost in pain and inhibition of the core.
Effects on the Hip
How about the hip? When the psoas gets weak, its long-axis function is lost and it stops stabilizing the hip into its socket. My best understanding here is that the femur tends to fall inferior and lateral, no longer has smooth internal rotation, and is not set in the socket. This can create hip pain or just be another contributor to lower back pain. The hip can't move, so the pelvis or lumbars move too much.
Here is another option for the hip. The gluteus medius gets weak, as do the deep external rotators. (This is a slightly different list of muscles, but the principle is the same: Key core muscles get weak.) The basic test: have them do a forward lunge and watch the knee. Does it deviate medially? This might be seen as a hypermobile hip or at least one that needs more control, rather than more mobility. This could create hip pain, but is more likely to contribute to pronation and medial knee pain.
What am I trying to say here? The same basic muscular pattern, of core inhibition with long-muscle hypertonicity, can create problems that affect multiple joints. There is a pattern. The specific weak links are going to vary from person to person. The expression, the site of pain, is going to vary. But the muscular pattern is going to be very similar. This was Janda's brilliance, seeing these patterns. Research since then has continued to clarify what we know about these muscular patterns.
The idea is to see the forest, not just the trees. Within the patient complaint, can you identify what joint areas are getting irritated? Can you figure out what muscles are not working right? Can you outline an exercise routine that will make a difference? Can you teach and motivate the patient to follow through with this?
The Joint-by-Joint Approach
Let's look at this from a different perspective. I talked above how the stuck places, due to the muscular pattern, were the lower thoracic spine and hips. I talked about how the hypermobile places include the lumbar spine and pelvis. Mike Boyle has popularized a concept called the joint-by-joint approach. I think it is brilliant.2 (Why did it take a trainer to remind us that the lumbar spine tends to be unstable?)3 Understanding this concept will change how you practice.
The main point here is to know how the body is organized, with areas (joints) built for stability and areas designed for mobility. The lower back and pelvis are primarily all about stability. When this is lost, the patient is likely to have or develop lower back pain. The areas above and below, the thoracic spine and the hips, need to have mobility to "save" the lumbar spine. When the patient cannot move above or below, the lumbar spine moves too much, and discs and facets get irritated.
Our job is to restore mobility to the stiff areas and to train stability for the unstable areas. Boyle points out that the hip can go both ways: into too much rigidity or into too much mobility. Think of the archetype of the older male who has lost internal rotation and flexion of the hips as the rigid hip. Think of the archetype of the hypermobile younger female, whose knees collapse medially on lunging, as the overly mobile hip, with no gluteus medius and piriformis control of hip motion.
Where do these ideas lead us for chronic lower back pain? Is it any surprise that research on manipulation to the lumbar spine for lower back pain shows limited effectiveness? First, check the areas that have lost mobility. This needs to include the hip joints and the thoracic spine. Mobilize these first. Second, assess stability within the lumbar spine and pelvis. Can the patient do an active straight-leg raise without any twist on the table? Can they, when instructed to, bend forward without allowing the lumbar spine to flex? Train the patient to control these areas. Rehab is absolutely necessary for any chronic lower back pain if you want the patient to succeed.
Do the lumbar spine and the pelvis need manipulation? The answer is usually yes, but I would say this: do an accurate assessment of which joints are actually stuck. Use lower-force methods, as you are not going to be able to just manipulate the segments you think you are aiming at, and you do not want to increase mobility in an already hypermobile joint. Do not manipulate the lower back over and over and over again.
Don't be satisfied with the "that feels better, doc" response if the patient is returning with the same complaint, day after day, week after week. It may be profitable business model. It is not a useful healing model.
A Case Study
And then, of course, a couple of patients, maybe they were outliers, maybe they were lessons, came along. One was an older male who had been in a motor-vehicle accident four months previous and was not getting better. His lower back hurt and his thoracic spine was very rigid. His previous chiropractor had tried to adjust him, but he would spasm after treatment. I tried something similar and had a similar result: spasm and increased pain.
Finally, I stepped back and saw his pattern. He had very rigid hips and a very rigid thoracic spine. All of his motion was occurring in the lumbar spine. When I left the lumbar spine alone and stopped trying to adjust his pain, he finally started to respond. He was willing to do the work, started to get more mobility in his thoracic spine, and started getting some core strength via the exercises. Finally, he started getting better.
References
With special thanks to my rehab teachers, including Craig Liebenson, DC and Mark Comerford, PT.
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