Sunday, September 2, 2007

The Low Back Pain : an Osteopathic perspective

(You can find a french translation of this article here)

"Low back pain is our daily bread", Mr D. Triana ( a teacher)was telling us. Actually I think he was saying that about nearly every type of complaints...

"You are as old as your back is" mentionned a brazilian tatooist.

In the UK, low back pain is one of the most common reason for time lost from work. The NHS spends more than 1 billion GBP/year and lost of productivity and sickness benefits cost the taxpayer another 20 billion GBP/year.

In this post, I'll expose the Osteopathic perspective of a low back pain, explaining different reasons that can cause this discomfort and what can be done to prevent it.

A quick anatomy review :

The low back comprises 5 lumbar vertebrae (L1 to L5), the sacrum, the coccyx (tail bone), 2 iliac bones which, with the sacrum constitutes the sacro-iliac joints. All of these bones are held together with rather thick ligaments (eg : ilio-lumbar, sacro-iliac, ischio-coccygeal ligament...)
Between each vertebrae there are discs which are composed of two parts : a liquid part in the middle, the nucleus and a fibrotic part which surrounds it the "annulus fibrosus".

A lot of muscles are present in the low back, long and short one :

The long one are generally attached to different bones or fasciae and will have an important postural "role"(eg : psoas, piriformis, QL, thoraco-lumbar fascia, gluteus...)
The short ones are little muscles which are attached from one vertebrae to another. These are the ones that if in spasm will "lock" a vertebrae and create an osteopathic lesion. if an "intertransversarii" muscle on the right gets into spasm between L2 and L3 then L2 will side bend on the right. To counteract this, a bigger muscle, the left Quadratus Lumborum will contract to counter balance and neutralise the lumbar spine.


  • Facet lock /Somatic dysfunctions :
    • This is the essence of Osteopathy : the "Osteopathic lesion" (please report to previous post for a definition). This concept is really interesting at a vertebral level. After a trauma, a compensation or a visceral dysfunction (...) little muscles attached to the vertebrae will spasm. Often this reflex mechanism aims at protecting the surrounding structures by limiting the movement of the vertebrae. What seems to be beneficial on a short term is quite pathogenic on the long run : as this reflex has difficulties to relax it creates a series of compensations which in return makes a lot of muscles to work harder and put strain on different surrounding structures. A vertebral lesion might be described as follow : L2 is in Flexion, Left side bending , Right rotation. This means that this vertebrae moves easily in these directions but poorly in the opposite directions.

      • Pelvic imbalances :

      The pelvis is crucially important : this is where the ascending forces (from the legs) and the descending forces ( from the spine) interact with each other. Each articulation of the pelvis (both Sacro-iliac joint and the pubic symphysis) needs to be relatively free. It will help the pelvis to adapt and compensate forces interacting at that place. Over time and traumas, some of the joints of the pelvis tend to become restricted. They often do so by adopting an excessive pattern.

      The coccyx (also known as the "tail" bone ) is a very important little bone : we can compare it to the "rudder" of the spine. Any fall on it will restrict its movement and will heavily compromise the biomechanic of the pelvis and therefore the biomechanic of the whole body.

      The most common pelvic patterns :

      -anterior rotation of one of the ilium
      -posterior rotation of one of the ilium
      -upper slip of one of the ilium
      -inflare or outflare of an ilium (opening or closing)
      -the sacrum will be described through its flexion/extension, side bending and rotation
      -the coccyx will be mostly described through its flexion/extension and side-bending

      Example of a common pelvic pattern :

      Anterior tilt of the right ilium associated with a flexion, left rotation and left side-bending of the sacrum.

      A "healthy" pelvis is not necessary a balance pelvis, but a pelvis in which all the joints are mobile. If the pelvis is rigid, one has more chance to injured a ligament, a muscle or a disc as the transmission of the force will be quicker and the adaptation poorer.

      • The Visceral Sphere :

      The organs are very important and have a great influence on the musculo-skeletal system. The medical field acknowledge that in acute cases one may feel some reffered pain from an organ but it seems to completely forget that a dysfunctional organ can also give some musculo-skeletal pain and greatly affect the posture of a patient.

      There are different ways an organ can affect the complaint of a patient :

      - imagine a patient with a spastic colon; the colon is attach on the psoas and on the diaphragm. If the colon tenses up, the psoas may react the same way and the diaphragm will see its amplitude decreases. In the case of the ascending colon, the patient might complain of a low back pain on the right side from the sacro-iliac joint to the lower ribs.

      -In the case of a ptosis of the stomach (or hook shape stomach) the patient will adopt an increase flexion of the upper thoracic. One way of preserving the balance can be for the lumbar erector spinae muscles to contract in order to pull back the body of the patient. The low back muscles will work more than needed and the patient will complain of a tired low back at the end of the day.

      -Other organs can affect the low back such as the kidneys, the duodenum, small intestine, uterus, ovaries, sigmoid, prostate... The influence of an organ can be mechanic, fluidic or neurologic (and psychologic ?)

      -Don't forget that the diet (food, liquid, drug intake) is very important and may influence greatly an organ and therefore the body.

      -Scars may also inluence the posture and therefore influence on a low back pain (see post on scar and posture)

      • Ascending Chain :

      Ascending chain is a term which designs any osteopathic lesions coming from below (in this case the leg) which will influence a compensation above. A short leg, a long one, a flat foot, an old knee injury(...) are factors which will influence on our gate and therefore on our pelvic pattern. Again, an excessive pelvic adaptation increases greatly our chances to develop a low back pain.

      • Descending Chain :

      Descending chain is the opposite. It is a lesion coming from above which will affect below. An old fractured clavicle will limit the range of movement of a shoulder. The gait of the patient might be affected as the arm does not swing as it should during the walk. A scoliotic pattern of the spine is developped which will affect the low back and the pelvis of the patient.

      Some Osteopaths claim that a TMJ problem (jaw joint) or dental problem can create a low back pain. Why not !? Personnally I never met such a case, maybe I should say : I never diagnosed such a case. I am certainly still too narrow minded in my osteopathic approach.

      Any Osteopathic lesions will increase the biomechanical stress on the body. It is believed amongst Osteopaths that such stress on the long run make muscles, joints, ligaments work harder than they should. After years of poor compensations, one is more likely to develop some wear and tear: some osteoarthritis. Increasing the mobility of the body, reduces the mechanical stress which affects it and over the years "should" decrease the severity of osteoarthritis (the "should" is there as I am not aware that any studies have been done to verify this ascertion).

      The medical and osteopathic diagnosis are not opposite the one with the other. The medical diagnosis gives an idea of the state of the painful structure while the osteopathic diagnosis tries to understand the reason of this problem. While the allopathic approach will concentrate on the symptom, the osteopathic approach tries to "treat" the cause.