Monday, November 20, 2006

Redefining Lower back pain, Sciatic Pain and other Symptoms in the lower kinetic chain, a mechanical definition

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.

The problem with back pain definitions to this point is that the symptoms are what are defined, and then treatment is based on the 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 muscular breakdown, poor firing patterns (groups of muscles that work together to achieve movement around a joint. A poor firing pattern results from shortened and weakened muscles that do not generate enough force to move as joint properly, requiring the body to recruit surrounding muscles into the action, causing an area to tighten). 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 these joints 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. Promotion of symmetry will help avoid this process.

Many researchers such as Vladmir 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 ligamenture.

Buried in all this information that has been published over the years is a most appropriate definition which is of a mechanical nature.

Back pain, Sciatica, Knee Pain, Lumbar Disc problems are a function of gait. The more efficient and symmetrical this persons 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 (see 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, inflexibility of the legs which will in turn reduce the flexibility of the person who has this type of mechanics and sacro iliac 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 multifidii 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 good doctor will look at body style, evaluate the symptoms and have an understanding of 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 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.

Herniated discs are a function of this system going bad. Since the body does not tolerate asymmetries, asymmetries in gait will cause shearing forces in the gait cycle resulting in a process called creep. 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 (break through 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).

Improving body mechanics using intelligent treatment will likely decrease ones likelihood for herniated discs, knee problems, sciatica and many upper back conditions.

While this is not your standard definition, it will lead to more intelligent treatment. Since back pain is a gait issue as I have shown, treating it as such yields more reliable results. Perhaps, this is why some chiropractors are able to yield better outcomes for the condition (most studies support this).