low back mysteries

[Danny K]

okay...I know there have been posts on low back and the stubborness of them..I have bad luck when it comes too assisting anyone with low back pain...usually when the back has been let to get really bad..for instance, a gentleman came in with a fresh low back strain..he was lifting on his job (he's a fireman) and he immediatly felt his back "go out" two days later his dr. told him to come in for a massage...he left not feeling better....then yesterday a client of mine came in and her low back hurt extremely bad...she's had back pain for a long time and I gave her a series of massages 6 months or so ago, she was coming in once a week and with every massage she felt better and she said it "fixed her back" and she quit coming, well, it got very bad again and she let it get very bad and she came in....her lower back hurt so much she could barely stand the feel of a light touch...she said it gets worse when she sits in her desk at work....when she takes time off of work she feels better...but now shes in extreme pain...she came in and wanted a half hour...i did very light massage as she was so sore.. I called to follow up and she said that night she was in extreme pain..could barely move and even her leg hurt..she went to the dr. and he said the massage may or may not have had anything to do with it...but of course i feel guilty...and i'm beginning to wonder if i am not doing it right massaging the back..but i always err on the side of caution and take it very easy on the low back....any ideas??? sorry this was soo long..ps does biofreeze help with low back? I tried it on the gentleman and he said it did not help.

 

[knight]

Generally low back pain is caused by weakness/tightness in the deep abdominal muscles. When the psoas and/or illiacus is very contracted, a person has that "can't stand up straight" pain. The key, then, is to slowly, gently stretch the abdominal muscles, work out the trigger points in the abs. allowing the overstretched back muscles to relax and shorten back to the length they were intended to be.

The QL's in the low back may also need to be worked. They are also very deep, and some books refer to them as the of the deepest abdominals.

With the client supine, have them raise one knee and then slowly, gently sink into the tissue on the side with the raised knee. Palpate to find the shortened muscles, and then very, very gently massage and elongate those.

Sometimes there is a huge difference in once session, but it generally takes several sessions for lasting relief.

 

[smallvoice85]

I've also found that working the hips is essential for relieving low back pain. This is my favorite technique for releasing tension throughout the hips (glutes, piriformis, etc). This whole technique is done through the sheet. Begin with some compression/cat paw and gentle rocking to the gluteal muscles, bilaterally. I then stand on a footstool next to the table, beside the hips. Facing the feet, I place one hand on each glute, the heels of my hands along each side of the sacrum. I then do alternating compression to one glute and then the other. I move my hands outward toward the greater trochanter and then back again to the sacral border. Next, I place my hands (one on top of the other) directly on the sacrum and compress down. Holding the compression, I move my hands in a slow circle, first clockwise and then counterclockwise. This massages all the borders of the sacrum, warms the sacral fascia and stimulates the cranial-sacral fluid flow. You can experiment with various sacral compression techniques here – alternating pressure on one side of the sacrum and then the other. You can also hit the acupressure points (on either side of the sacrum and in the sacral fossa). Finish with steady pressure on the center of the sacrum again, and then lift your hand until there’s barely any pressure and gently begin rocking your hand. The rocking motion will first move the client's sacrum and hips and usually your whole client’s body will follow in a rocking motion.

Oftentimes, it takes 24 hours for clients to feel the benefits of this work. I've had many clients get up from the table, still feeling stiffness in their low back, but when they wake up the next morning, they feel great.

 

[aightman]

the multifidus

Below is a short version of a handout.
Bottom line is that most people (including myself) must do stabilization exercises to strengthen their inner unit.
Back pain is complex, to say the least, but heres a common scenario........
The multifidi from the sacrum up to lumbar 3 are often involved with muscle-based back pain.
The Multifidi to the L3 transverse process irritates QL, and that activates the iliocostalis.
Glut medius- especially the posterior part that attaches to the PSIS- and glut minimus are almost always involved with chronic LBP

THE HANDOUT
The INNER UNIT became accepted as a term describing the functional synergy between the
1) Multifidus
2) Transversus Abdominis
3) Pelvic floor muscles
4) Thoracolumbar fascia
5) Lumbar portions of erector spinae
6) Posterior fibers of the internal oblique

When working properly, these muscles provide the necessary increases in joint stiffness and stability to the spine, pelvis and rib cage to provide a stable platform for the big muscles.

The inner unit is under separate neurological control from the other muscles of the core. This explained why exercises targeting muscles such as the rectus abdominis, external obliques, and psoas, (the same muscles exercised in traditional abdominal conditioning programs common allover the world) were very ineffective at stabilizing the spine and reducing chronic back pain.

Exercising the big muscles (prime movers) was not providing the correct strengthening for such essential small muscles as the multifidus, transversus abdominis and pelvic floor muscles.
In a sense, as the big muscles (outer unit) become stronger and tighter, the delicate balance between the inner and outer units becomes disrupted.

This concept is easier to understand using the pirate ship model. (picture missing)

Although the large guy wires (outer unit) support the mast of the pirate ship, its functionality is completely dependant upon the support provided by the small guy wires which represent the multifidus and inner unit muscles in this analogy.

The mast of the pirate ship is made of vertebra, which is held together (stabilized) by the small guy wires running from vertebra to vertebra, just like the role of the multifidus (a member of the inner unit) in the human spinal column.

Although the big guy wires (representing the outer unit) are essential to hold up the mast of the pirate ship (our spine), they could never perform this function effectively if the small segmental stabilizers (inner unit) were to fail. By viewing the pirate ship's large guy wires, it becomes easy to see how developing too much tension from the overuse of exercises such as the crunch, could disrupt the posture of the mast, or spinal column in the case of a human.


Bottom Line: most back involve problems with the MULTIFIDUS
While the multifidus is really a group of muscles, it's referred to in the back literature in the singular. However, it is not just one big muscle that runs all the way from the top to the bottom. Instead, it takes many individual multifidus muscles combined, each crossing two to five levels of vertebrae, and often several layers thick – especially the lumbar multifidi. In this way, the multifidus is capable of gaining fine control over just a single segment of the spine.

Researchers are now finding out that in some people with low-back pain, it's not always the whole multifidus muscle group that is the problem. In many cases, it's just a single multifidus muscle at only one level of the spine that's not working properly.

Multifidus is different from all the other back muscles in that each multifidus muscle gets its nerve messages from only one level of the spinal cord. Anatomists call this being segmentally innervated. What this means to the multifidus muscle is that it can be more prone to having problems. Other back muscles have nerves coming from several different levels of the spine to power them, so that if one nerve doesn't work well, it still has the others to help it out.

Another interesting anatomic fact about the multifidus is that it's connected to each of the small joints in your spine, also known as the facet joints. It does this by way of its attachment directly to the joint capsule. This is significant for the spine's function, as the multifidus can exert a pull on this capsule and prevent it from becoming caught inside the joint as you move your back throughout the day.

The multifidus is the only muscle on the posterior sacrum, thus - the only muscle directly stabilizing the lumbosacral joint. The lumbar erector spinae consist primarily of tendons and cross several joints so they have little to do with lumbar stabilization

Experimental Observations of Those With Back Pain:
·Muscle activation -- less activity of Multifidus at unstable level during concentric back activity, suggesting decreased muscular protection at the hypermobile segment.
·Fatigability -- Patients demonstrated greater fatigability of the Multifidus. This even occurs in elite athletes with history of low back pain (LBP).
·Size and consistency -- Many patients may have severe changes in Multifidus after lumbar surgery. In patients with unilateral LBP there is marked side-to-side asymmetry of the size of the MF, with the smaller muscle on the symptomatic side and level. Changes can occur within 24 hours of injury.
·Recurrent LBP-- Multifidus recovery is not spontaneous upon pain relief or when patients returned to normal activity levels. Patients with recurrent LBP typically have pathological changes and selected atrophy of type II fibers. Multifidus dysfunction reduces the ability of a facet joint to transmit loads; therefore loads are shifted to the disc and ligaments.
·Multifidus Atrophy--wasting may occur without erector spinae atrophy
·Surgical Patients. Patients with negative outcome s/p diskectomy may have persistent "selective multifidus fiber atrophy", "pathological inner structure changes",

 

[Disasturr. <3]

That is very interesting, Palpateit. How exactly, then, do we best treat low back pain? What types of exercise should we be doing to strengthen the multifidi and avoid low back pain, ourselves?

 

[Confusing123]

Thanks for posting that, palpateit. Very interesting info, indeed.

 

[juli]

very informative..thank you so much..

 

[crabbypatty]

yes...this poor woman didnt barely want to even be touched!!!! her back was sensitive to even be touched..and not to mention she only wanted her back worked and is very body conscious and over weight..so, I am at a loss with this poor woman..she went to her dr. and of course all he did was give her muscle relaxants.. so, with that being said, how would any of you massaged her?

 

[TiffyG]

Jacqueline wrote: yes...this poor woman didnt barely want to even be touched!!!! her back was sensitive to even be touched..and not to mention she only wanted her back worked and is very body conscious and over weight..so, I am at a loss with this poor woman..she went to her dr. and of course all he did was give her muscle relaxants.. so, with that being said, how would any of you massaged her?

Jackqueline, if you have a client who is so self-conscious that she refuses to allow you to work the areas that will help her, then I would suggest you refer her to a physical therapist. They'll work on her fully clothed with techniques where there's no need to be self-conscious (traction, ultrasound, e-stim, contrast therapy). Most importantly, they'll do a thorough assessment for injury, as well as teach her stretches and gentle exercises she can do at home to provide relief.

Palpateit wrote: Bottom line is that most people (including myself) must do stabilization exercises to strengthen their inner unit.

RofS wrote: How exactly, then, do we best treat low back pain? What types of exercise should we be doing to strengthen the multifidi and avoid low back pain, ourselves?

I did an internet search and found a website with a series of back exercises. The Alternate Superman is the safest for people to do who are recovering from low-back injuries. And the Horse Dance is supposed to help with spinal alignment. Palpateit, what do you think of these exercises?

http://www.peakfitnessgroup.co.uk/back.htm

 

[E-rock]

Bliss,
Excellent idea!!! Thank you, I will definatley suggest that!!!!

 

[mushroom]

In addition to the other very wonderful ideas for relief of low back pain, etc., I'd add trying a craniosacral pelvic diaphragm release.... Client has to rest the sacrum on one of your hands while your other hand rests gently on the lower abdomen approximately opposite the sacrum..... hold still and let the "magic" of craniosacral help loosen some of the offending musculature in the pelvice diaphragm and the attachment points of the hips.............

 

[learning_to_live_616]

Yes, the alternate superman, and horsedance exercises on the above link are the main exercises to start with. I've created many exercise variations for myself based on this theme of "uneven loading" - that's what I call it. Simply put - uneven loading will force the spine and pelvis to twist, or rotate. Result = The multifidi, transversus, and obliques must isometrically contract to prevent twisting of the spine and pelvis. The Rectus abdominis and erectors cannot perform this function, so they get left out (which is the goal)
Below is my favorite spinal stabilization book. It contains beginning, intermediate and advanced levels. easy & lots of pics.

Spinal Stabilization: The New Science of Back Pain, 2nd Edition (Paeforum.xxxack)
by Rick Jemmett (Author)

I love working the lumbar & sacral multifidi. I only use a tool (after fascia work and warming.)
The lumbar multifidi are far thicker (more layers) than any anatomy text ever shows. On cadavers that died bed-ridden and in their 80's the multifidi can be an inch and 1/2 thick at L4. Obviously, much thicker on a healthy non-cadaver. The ercetor spinae are far thinner at S1 - L3 than anatomy books show.

Below is a simple book (yet good) on why the multifidi are so important. Only a few exercises shown - basically the same ones shown on the above link.

The Multifidus Back Pain Solution: Simple Exercises That Target the Muscles That Count (Paeforum.xxxack)
by Jim Johnson

 

[timdvrs]

Palpateit, thanks for the insight on the "inner unit" & the information on the exercises. I've started doing them myself, and I'm recommending them to most of my clients. So many have a classic tension pattern of alternate hip & shoulder. I'm sure that's largely due to their inability to stabilize their lower spine/pelvis. I think those exercises will help.

 

[Cute Latin Girl]

One are of concern with the alternate superman is if you are performing the exercise in hyperextension. Moving into hyperextension does place undue stress on the vertebral disc.

Now on the other hand, which is worse, a dysfunctional state for 24 hrs a day, or an extended direct state for the duration of the exercise? Current dogma seems to say the exercise is worse for the back, but I digress.

Because of this, you may want to perform the exercise in a more neutral state, such as on all fours, or with their stomach on a ball. Naturally, extensions over a ball are harder stability/strength wise, but will work better. Its a matter of weakness.

One method of assessment of strength is using the plank exercise, which ironically is also a good strengthening exercise. Typically in the personal training world, the sure for weak abs is direct work on the movement most commonly associated with abs, flexion. In the case of low back pain, we need to take into consideration the fact that if the back is weak, the pelvis isn't so hot either. Simple abdominal stabilization exercises without heavy hip flexion exercises, eg. ab crunches, leg raises, etc.

Be sure to address the ligature of the low back, namely Iliolumbar ligament and sacrotuberous ligament. There have been instances where a client would return still in pain several days later. Soft tissue manipulation was performed as was ligature treatment and joint manipulation, but after a few days, the ligature begins to ache due to the new length required. Assessment often reveals the pain, while similar, is not the same pain, its just the ligature reacting.