Indy Myopain

R  E  L  I  E  F        C  E  N  T  E  R

Low Back & Sciatic Pain

Low back pain is the leading cause of long-term disability worldwide.

1. The lifetime incidence of low back pain is 58-84%,

2. and 11% of men and 16% of women have chronic low back pain.

3. Back pain accounts for 7% of GP consultations and results in the loss of 4.1 million working days a year.

4. More than 30% of people still have clinically significant symptoms after a year after onset of sciatica.

5. Billions of dollars are spent, trying to get pain relief and is currently focused pain relief via, exercises, braces, injections, surgery, massage, nerve ablations, massage and even trigger point therapy.

Low back pain becomes sciatica when the back pain extends down one or both legs.

Make a positive clinical diagnosis of low back pain and sciatica. Imaging should be done only in specialist care settings and only if the result is likely to change management. Think about the possibility of serious underlying pathology. Consider risk stratification to inform discussion about treatment options.

Assessment of low back pain and sciatica physicians and patients

Physicians, DO, CP should make a positive clinical diagnosis of low back pain and sciatica. Imaging should be done only in specialist care settings and only if the result is likely to change management.

1. Consider and rule out the possibility of serious underlying pathology.

2. Consider risk stratification to inform discussion about treatment options. Consider

3. Evaluate alternative diagnoses when examining or reviewing people with low back pain, particularly if they develop new or changed symptoms. Exclude specific causes of low back pain—for example, cancer, infection, trauma, or inflammatory disease such as spondylarthrosis.

•Consider using risk stratification at first point of contact with a healthcare professional for each new episode of low back pain with or without sciatica, to inform shared decision-making about stratified management.

•Based on risk stratification, consider:

– Simpler and less intensive support for people with low back pain with or without sciatica who are likely to improve quickly and have a good outcome (for example, reassurance, advice to keep active, Myofascial Trigger Point Therapy and guidance on self-management).

–More complex and intensive support for people with low back pain with or without sciatica at higher risk of a poor outcome (for example, exercise programs with Myofascial Trigger Point Therapy).

•Do not routinely offer imaging in a non-specialist setting for people with low back pain with or without sciatica. Magnetic Resonance Imaging of the Lumbar Spine in People without Back Pain | NEJM Explain to people with low back pain with or without sciatica that, if they are being referred for specialist opinion, they may not need imaging. . BMJ 20172017;356:i6748

Patients with low back pain and/or sciatica.

If your surgeon is advising you need immediate surgery and your primary care physician is saying wait, then you know how much a problem, getting better is going to be.

Practitioners have very different approaches that all work to some extent: 100% to20% better!

Doctors will focus on structure issues and resultant inflammation.  This means they treat stenosis (arthritis) of the spine impinging of the spinal cord, bulging or herniated discs.  They use steroid injections to relieve the inflammation caused by the impingement pressing on a nerve root often located in L4, L5, S1. If you get the injection, ask for a very long-acting pain reliever such as Marcaine. 

Chiropractors usually focus on the spine and its alignment, often requiring daily treatments for weeks to realign the vertebrae.

Physical Therapists will use exercises such as the McKenzie Method to heal you over weeks and months, sending you home with 7 exercises that will keep you busy.

Lastly, there are trigger point therapists that pursue the muscular and soft-tissue avenues.  Nerve root entrapment, piriformis syndrome, psoas, rectus abdominis or glute Minimus!  This was my domain until, I found we often need to add exercises and stretching to complete the picture.

Those McKenzie exercises are a great start!  I love them, but sadly, I have ignored them do to lack of time during therapy.  Now, I have seen the light and changed my methods!

When do you know you have low back pain/sciatica that needs to be treated by who?

1.       Did this come on suddenly?  Yes? No?

2.       Does this condition come and go? Yes? No?

3.       Does this condition get worse when you bend forward? Yes? No?

4.       Does this condition get worse when you bend backward? Yes? No?

5.       Do you lose your balance or get dizzy when doing 3 or 4?  (Go to Doctor)

Do xrays, CT scans and MRI’s help?  Shows structure but not pain.

f your pain goes down your leg for a while and then gets better, then if it is due to a bulging disc how does the bulging disc go away and then come back?  Same with the stenosis. If the pain comes and goes, then logically, the stenosis or disc does not come and go away, something else must be happening. 

If the pain comes on suddenly or slowly, comes and goes or gets worse when you bend over, then come see me.  If the pain gets worse bending backwards, see a surgeon now.

Several studies of MRI and asymptomatic people:

Dr. Robert Gerwin relates a study done at Johns Hopkins involving 200 MRI’s done on a population of people, ages range from 18-99. The second criteria were that no-one could have any pain for 7 years!

They found study to be full of spines with cracks, bulging discs, stenosis, ruptures, arthritis, and ruptured discs. The trend was the older the patient the higher the frequency and types.

The Florida Blue Cross did a similar study.

What is going on with low back pain and sciatic?

Physicians, DO’s, and Chiropractors are all in similar schools of thought and I agree.

The spine when we are young is a beautiful “S” shape. As we age and our lifestyle, the spine becomes more “C” shaped. Factoid: We bend forward about 3,500 to 4,500 times daily and some workers even more! Bending forward puts our spine in a “C” shape. Our spines are made of vertebral bodies separated by spongy discs. When we bend forward, spongy discs compress on the anterior side and apply reward pressure causing the disc to push toward the back side. Two types: lateral posterior and posterior hernias. Overtime, the contents of the disc may begin to leak out or rupture. The lateral disc bulges are the most common for back pain and sciatica. They, protrude toward the L1, L2, L3, L4, L5, S1 nerve root which combine to form the sciatic nerve, pressing and thereby irritation the nerve root.

But this not the only thing that causes back and sciatic pain. The represents only 20% of the population. 80% of the time, muscles that are shortened or contain trigger points and surround the nerves, irritating and compressing. Where are these muscles?

Muscles that exist close to the spine and become shortened, tight, or cramped also irritate the nerve roots. (Travell & Simons)

Muscles in the buttocks are also suspects as the sciatic nerve passes near or through several muscles: Piriformis, Glute Minimus (pseudo sciatica! (Travell & Simons), Glute Medius, Superior Gemelius, Obturator Internus, Superior Gemelius, Inferior Gemelius, and Quadratus Femoris. All of these are candidates for sciatic nerve entrapment or irritation.

Abnormal pelvic tilt is a contributing factor in orthopedic and muscular causes.

I treat the hip flexors and Rectus Abdominis and examine and correct for Hyper pronation of the feet also contributes.

Ah Yes,

All we must do is restore the patient’s spinal column to an “S” shape and things usually get better. SIMPLE? Not so fast!

Surgeons do surgery! Install plates! (10-20% of the time).

Doctors will prescribe medications, braces, physical therapy.

Trainers: exercise and stretch.

Physical Therapists use strengthening and stretching methods such as the McKenzie exercise your muscles until the proper “S” curve is restored . (For the rest of your life!) and examine your lifestyle for perpetuating factors.

Chiropractors will adjust your 4 times a week for 8 to 10 weeks. 80% better.

Massage therapists will massage you weekly for the rest of your life. 10-20% better.

Myofascial Trigger Point therapists say: ‘It’s your tight muscles, nerve roots, posture, lifestyle, perpetuating factors and do McKenzie exercises! 70% better.

The truth lies near to all methods have a significant contribution and we should follow the orthopedic guidelines that state: Use conservative measures for 6 to 8 weeks before cutting!

My approach as a Trigger Point Therapist has recently changed and is now as follows:

  1. Get a history.
  2. Listen to the patient.
  3. Evaluate for perpetuating factors, correct.
  4. Perform Range of Motion exam, noting muscles that are involved.
  5. Treat the triggered muscles and immediately stretch the patient following each               muscles release.
  6. Re-evaluate ROM for progress.
  7. Then perform McKenzie evaluation and stretching. From these results:
  8. Re-evaluate ROM for progress.
  9. Instruct the patient in which McKenzie exercises are appropriate.
  10. Ask the patient with each milestone how they feel. It the sciatic pain disappearing from the leg and concentrating in the low back (this is a good thing).
  11. Treat the back pain.
  12. Ask the patient if they understand what they are to do when returning home.
  13. Drink water!

This usually requires 3 hrs.

Three follow up sessions of 90 minutes.

Two one hour follow up sessions of 60 minutes.

If after 3 sessions, we are not seeing any improvement then I will suggest another type of therapy.

In conclusion: Each profession has their own little black bag of solutions for low back pain and sciatica. Each has found success, and each has value. But most only treat the symptoms and do not seek the cure or prevention. All of us needs to integrate our solutions and prioritize the order of treatment. Medical doctors, chiropractors and Osteopaths need to lead the solution and rule out serious medical conditions, then refer to trigger point therapists for neuromuscular therapy. Neuromuscular Therapists (NMT) & Trigger Point Therapist (TrPt) not only treat the pain, but also seek out the conditions of our bodies that is inhibiting our healing (perpetuating factors) and returning to a pain-free life. NMT’s seek out the root causes, provides the patient with techniques to end the perpetuating factors and advise on self-care methods. Physical therapists seek to strengthen weak muscles to provide a life-time free of pain, but often fail to understand that when a muscle has trigger points the muscle cannot be strengthen and often when exercised becomes worse.

All should also recognize; imaging shows only structure and not pain. When the imaging shows minor conditions then time is available, option for a conservative approach: Neuromuscular Therapy (trigger point). All should keep in mind that 80% of time, there are better solutions than surgery, medication, and physical therapy. Often, it is just your brain and muscles in confusion causing pain, loss of range of motion and weakness.

Steve Maschmeyer