A Hip Solution to Low Back Pain

Welcome to the new Physical Therapy world. Gone are (or should be) the days of the ultrasound, hot pack, and nice massage. No longer do we treat only the location of pain. Each patient who fell through the cracks after their e-stim machine turned off begged for something more, and the time has certainly come.

Say hello to your new Physical Therapist. Your new therapist doesn’t bother dusting the ultrasound machine as he or she is too busy examining movement. One hour of pain free walking after short term treatments is not enough. Your new Physical Therapist is asking why the pain always comes back after one has sat for too long. A manipulation is only magical if the pain doesn’t return after repeated bending. Physical Therapists don’t simply stop at the area of pain, they move on to determine why that area of pain is under so much stress during seemingly simple movements.

Shooting numbness down your leg while sitting? Piercing pain at your low back with only minutes of walking? Could it be that the answer to your problem is not a laser to damaged areas of your spine? Could it be that the reason the pain occurs while you are sitting is due to tight hip musculature? What if stretching the hip flexors could relieve the pain associated with the osteoarthritis found on the x-ray? Some colleagues of mine have recently explores the relationship between hip stiffness and low back pain here.

In a nutshell, every movement is comprised from multiple parts of the body. Even sitting, the most common position for todays common man is quite complex. Sitting in a low seat requires up to 110 degrees of hip flexion. Ideally, the pelvis will not tilt posteriorly, and the low back will not round into flexion. Unfortunately, most people don’t have 110 degrees of hip flexion. Sitting without hip mobility can result in excessive tensile stress to the low back, and therefore cause that aching low back pain after prolonged sitting.

You can have soft tissue done, a manipulation, or even surgery if you can find the right (or wrong!) surgeon. But, when you go back to sitting without the hip flexibility the pain will return.

It works both ways. Some individuals have tight hip flexors and therefore lack full hip extension while walking. This results in excessive extension at the spine, and/or a compensatory rotation at the pelvis resulting in unneeded torque at the spine.

Once again, any treatment at the spine is missing the cause of the dysfunction.

The Physical Therapy world is changing. You can now see your physical therapist without a Physician prescription in most states. More and more therapists are screening movements and looking for this type of hip dysfunction well before the low back pain even starts. Find yourself a great local therapist and determine the cause of the pain today. Check http://www.optimalmovementpt.com for more information.

What are your favorite hip mobility exercises? Stay tuned for the next blog to learn the best mobility exercises for the hip.

How can Physical Therapy help with my Low Back Pain?

This post continues the discussion on how we as physical therapists can best treat our patients’ ailments. Check out the previous post regarding treatment and communication of a patient with knee pain here.

“Well, the reason for your low back pain is that you have degenerative disc disease.”

or,

“You have a slipped disc at L4/L5 which is compressing a nerve.”

or,

“the arthritis in your back is equivalent to a 90 year old.”

Pretty scary huh? How can physical therapy help with diagnoses like these? Can physical therapy remove the arthritis found on imaging?

No it cannot. But perhaps there are more important questions to ask. I would assume that the more meaningful question(s) may be; Can physical therapy eliminate the low back pain I experience when I am walking my kids to school. Can physical therapy allow me to lift items from the floor, and therefore allow me to perform my household duties? Can physical therapy eliminate the discomfort I experience while sitting for prolonged periods at work, and therefore allow me to be more productive? Can physical therapy eliminate the discomfort I have while I play recreational sports so that I can get back to playing basketball?

The answer to these questions is yes. But, look at the disconnect that many patients experience. Originally, they seek out a healthcare professional with a complaint during some type of meaningful activity. Rather than receiving an answer or a long term intervention, the original complaint gets warped into a diagnosis of “degenerative disc disease”, “arthritis”, or “stenosis”. Could it be that what’s causing the discomfort is not the diagnosis, but rather faulty movement?

Why do we rely on imaging to dictate the cause of our discomforts? Look at this research article performed on individuals without low back pain. This study utilized MRI images on individuals without low back pain. Only 36 percent of individuals without low back pain had “normal” findings. 52 percent had a disc bulge, and 27 percent had a disc protrusion. This, once again, begs the question, could it be that what’s causing the discomfort is not the diagnosis, but rather faulty movement?

This is actually great news for individuals suffering from low back pain. Nobody can treat  a diagnosis of stenosis or arthritis. But a movement expert can assess and implement a program to help individuals who have pain with specific activities. Treatment begins with identifying faulty movement, understanding the reasons for the poor movement, and specific corrective exercises to eliminate the poor mechanics.

For example, take a look at this diagram;

No diagnosis is causing this discomfort. Poor movement places a high amount of stress on the joint, the disc, the muscles, everything. Change the movement, change the pain. 

That being said, sometimes the desired activity requires more strength and flexibility than an individual has.

This individual likely does not have the core strength to lift appropriately given this quick movement screen. In order to lift appropriately, she may require a strengthening regimen. Every body is different and requires an individualized assessment and program prescription.  In order to get here, push your diagnosis to the side and begin identification of movements which may cause the discomfort.

Optimal Movement Physical Therapy is dedicated to helping individuals identify and treat their movement faults. Visit our website or e-mail us at alan@optimalmovementpt.com so that we may help answer any questions.

Abdominal Bracing for Chronic Neck Pain

What’s causing the pain? How do I alleviate the pain for good?  These questions from our patients has led the profession down a new route. A route that no longer looks at just the source of pain, but also the cause of pain. It has led us to a new concept, dubbed “regional interdependence“.

In short, regional interdependence is looking at the whole body to better understand the cause of one’s pain location. As you can imagine, the education and treatment of a person will be quite different when focusing on the body as a whole rather than having tunnel vision solely on the area of discomfort. No longer are the days where physical therapists simply identify the source of discomfort and apply direct interventions solely to the source of pain. The profession has realized that the majority of our patients are not looking for the quick cure, but rather the long term answer. The latest from the profession has suggested intervening at the thoracic spine for pain located at the cervical spine, treating the hip for individuals suffering from low back pain, even interventions focused on the brain and understanding pain for treatments of chronic pain.

A piece of research that I was lucky enough to take part in during my Spine Rehabilitation Fellowship offers a new paradigm on the potential treatment of chronic neck pain. The research was part of a platform presentation at the 2014 APTA Combined Section Meeting in Las Vegas, and (keep your fingers crossed) will be available after it is published shortly.

The study may be the initial step to eventually show a potential relationship between trunk stability and chronic neck pain, offering a new approach for the treatment of chronic neck pain. A quick synopsis of the rationale:

Moseley showed that individuals with sub-acute neck pain also have impaired trunk muscle function.

This study showed a difference in the deep neck flexor endurance test exists between individuals with and without chronic neck pain.

This begs the question, will trunk stabilization improve the endurance time during the deep neck flexor test, therefore improving the endurance deficit that may be the cause of discomfort for individuals with chronic neck pain? The initial study shows that there is a difference in endurance time when an individual is given manual bracing at the trunk. Of course, there are several more steps needed before trunk stabilization exercises are prescribed for individuals with chronic neck pain.

A basic summary of the research: trunk stability may play a big role in the long term treatment of chronic neck pain. No longer are the days of simply looking at the location of pain for treatment (cervical spine), but rather towards the whole body for the cause of pain (trunk stability). The physical therapy profession is ever changing, and with some more research the new paradigm for treatment of individuals with chronic neck pain may include trunk stabilization.

www.OptimalMovementPT.com

Low Back Pain Paradigm Shift

Ten years ago, if you had low back pain and saw a Physical Therapist, you would most likely be prescribed “core strengthening” exercises. In fact, even today, you will most likely be given some exercises for the muscle group which provides stability at the low back. It’s not a bad idea, it works and there is a lot of research to support this paradigm. It’s become so commonplace that the argument is no longer whether you should train the abdominals, but more on how you should strengthen this muscle group. Brace or hollow? Sit-up or plank? There is multitude of articles and blogs on which exercises are best for persons with low back pain, and professionals often prescribe them without a second thought.

But, what happens when getting stronger doesn’t work? What are we missing?

The truth is, nobody has a “strong” core. It’s something we all have to work on. That’s why we can get away with prescribing it to everyone, because it always tests weak. Sure, some people have a stronger core than others, but in relation to the stiffness of the hip or shoulder, the trunk is often less stiff. Further, some people with a strong core still have back pain. So, again, what do we do when simply getting stronger doesn’t work?

That’s when it’s time to look at the movement. Look at the person’s function. Which movements are they required to do? What are their preferred movement patterns? Are they using the strength they already have?

Case in point: This client complained of low back pain and sciatica for the past 6 months. We began looking at abdominal strength as part of our objective exam only to find that she had great strength. When pointing this out to her, she noted that she is quite active. She hikes, does yoga, runs, stand up paddle boards, does pull-ups and planks. How could she have back pain?

Standing posture with measurements showing mild swayback posture.

The examination did not show many treatable impairments. When a client has a fairly clean strength and mobility examination, we get to move on to function. This client is very active, but the activity she does the most is holding her one year old son who weighs nearly twenty pounds. So, it’s time to check out her function.

Increased swayback posture when standing with twenty pound load (aka her son).

As you can see, the standing posture changes dramatically. The shoulders are no longer lined up with the hip, but they have shifted posteriorly. This client has shifted into extension when she holds her child. This excessive extension is just enough stress through her low back to cause some discomfort.

So, if she has enough strength, then, what is the treatment?

There is no exercise that will magically cure this shift. The only exercise or treatment for her is awareness. After a few small corrections, we are able to prescribe her only “exercise”.

Improved standing posture with 20 pound weight.

No rehab exercises needed. In fact, she is already doing more than I ask most patients to do anyways. She just needs to use what she already has and contract her abdominals while holding her son. She has all the moving parts to perform this movement optimally, and her rehab sessions have been cut from several to one.

This client is a great example of a client with low back pain who will not respond to abdominal exercises. The paradigm has shifted. It’s time to look at function. It’s time to look at movement. At Optimal Movement Physical Therapy, we assess, diagnose, and treat movement.

www.optimalmovementpt.com

Rebecca is the owner of be. Her mission is to inspire and educate people to live healthier and happier lives by spreading knowledge about the importance of nourishing their bodies with the best food. Check out her site at http://www.benourishedbehealthy.com.