Redefining Lower back pain, Sciatic Pain, and other lower back symptoms, a mechanical point of view.
By William D. Charschan C.C.S.P., I.C.C.S.P.
Lower back pain is a condition that costs Billions per year to treat, yet, treatment has been inconsistent at best, it misunderstood at worst, and has been treated with varying levels of success. One of the most studied groups with the most consistent results has been chiropractors, followed by Physical Therapists, followed by medical treatment which includes surgeries and medication. A recent study published in JAMA performed at the Veterans Administration is now recommending that medical treatment, combined with chiropractic care offers significantly better outcomes than with medical management alone.
The problem with back pain definitions to this point is that lower back symptoms are what is defined, and then treatment is based on the lower back symptoms. Unfortunately, back pain, sciatica, and even knee pain are caused by malfunction of the lower kinetic chain (the series of joints including the ankle, knee, and hip, with secondary effects on the shoulder, elbow, and wrist), asymmetry and inherited traits which allow for either efficient or inefficient mechanics resulting eventually in breakdown we see as pain, sciatica, arthritis, worn-out knee or hip joints and secondary effects into the upper body in the neck, shoulder, elbow.
Poor mechanical function results in the muscular breakdown, poor firing patterns (groups of muscles that work together to achieve movement around a joint). This idea is discussed in detail in the book Cheating Mother Nature, what you need to know to beat chronic pain) It is the author’s opinion that most herniated discs in the lower back and neck, are caused by asymmetry in the way the joints are moving when a person is built asymmetrically. This type of body style will impart shearing forces to the discs in the spine creating a process called creep (take a piece of plastic, keep on bending it until it begins to break is what we call creep). Creep will cause discs to fail and degenerate due to abnormal wear and tear. The promotion of symmetry will help avoid this process.
Creep is structural fatigue (not dissimilar to taking a piece of plastic and bending it until it develops cracks). Since asymmetries will cause excess motion and wear and tear at the joints, eventually, the material (annulus fibrosus) can fail and cause the disc material to either bump out (bulge), herniated (breakthrough inner but not outer fibers, extrude (break through the outer surface) or become an extruded segment (disc material in the spinal canal requiring surgical intervention).
Many researchers such as Vladimir Janda, Brian Rothbart, and many others have worked with kinetic chains, function, or malfunction. Rothbart had shown in his engineering model how the body implodes or rolls anteriorly the more the feet flare out (overpronation of the feet). Many of my own articles discussed a concept called the basic pronation accommodation pattern that explains what happens with this implosion effect to the muscles and ligature.
Buried in all this information that has been published over the years is the most appropriate definition which is of a mechanical nature.
Back pain, Sciatica, Knee Pain, Lumbar Disc problems, and other lower back symptoms are a function of gait. The more efficient and symmetrical this person’s body style is, the more likely they will experience chronic back, leg, knee, and hip pain and secondary problems in the upper body.
The more the foot flares out, the more the knee rolls in. If you have one leg that either turns out or in as compared to the other, the leg that flares out will create a functional short leg and will act as if it is shorter than the other leg. This causes an effect called pelvic unleveling. The side that flares out will also tighten up over time, with most of the muscles in the lower kinetic chain involved. This will cause movement of that side to become inefficient and this leg will eventually tighten in the back, creating tightness into the hamstring. The body will compensate with the quadriceps and psoas muscle (main mover of hip and strongest muscle in the body) to tighten on this side. This torque on the pelvis will lead to lower back pain, the inflexibility of the legs which will in turn reduce the flexibility of the person who has this type of mechanics and sacroiliac or garden variety back pain. The pain is caused by the side of overpronation locking up and the opposite side straining. Typically, the side of strain is the side of pain in sacroiliac pain syndromes. The longer this persists, the tighter the quadratus, erector, and multifidus muscles get creating further reduced mobility and upper kinetic chain malfunction which is why tight hip flexors will cause neck pain as this condition locks up and in the worst cases rotates the rib cage to the side of overpronation, often producing pain in the shoulder blade on the opposite side.
As you can see, body style produces lower back pain and many other problems chiropractors have successfully treated.
Intelligent treatment of gait issues begins at the feet. This includes eliminating flat shoes and wearing foot orthotics which have proven beneficial in improving the efficiency of body mechanics. A thorough evaluation should consider your body style, your symptoms, and look for cause and effect. Treatment shall include myofascial release or similar method to improve muscular efficiency, improve firing patterns, and promote body symmetry. Exercises should be performed to enhance the effect of myofascial treatment and strengthen released tissues. The role of orthotics should be explained in layman’s terms to the patient, and they need to recognize that these inserts need to be part of their lifestyle. Secondary effects of treating body style issues will be an improvement in the way the upper body functions, fewer problems in the upper kinetic chain (shoulder, elbow, and wrist) and improved ability to move their neck.
Improving body mechanics using an intelligent treatment such as active evaluation and treat – test – treat protocols will likely decrease one’s likelihood for herniated discs, knee problems, sciatica, and many upper back conditions and other lower back symptoms.
While this is not your standard definition, it will lead to more intelligent treatment that is holistic and personalized to the individual, rather than to the symptom using one size fits all protocols that often are ineffective on resolving the mechanism behind the dysfunction.
Back pain ultimately is an expression of how we walk and move, understanding the mechanism behind the pain and then personalizing the care to the individual yields more reliable results. As recent as last year, the Annals of Internal Medicine made recommendations that suggested movement and movement-based methods should be the first approach for back pain, and medication, injections, and then surgeries should be the last options after conservative approaches failed to alleviate the pain.
Perhaps, this is why chiropractic methods are now becoming the first choice for many back pain sufferers.