“Low back pain is the leading cause of activity limitation and work absence throughout much of the world.”
Low back pain is one of the world’s major causes of disability, with incidence numbers rising every year in the adult population. Even scarier is that the prevalence of non-specific low back pain in children and adolescents is also rising. The lifetime prevalence of non-specific (common) low back pain is estimated at 60% to 70% in industrialized countries. Where is my low back pain coming from? Does everyone have the same low back pain? What is sciatica? What can I do to help my pain? These are all questions I’m sure we have all asked at some point. Well, here is your one stop shop for all of the answers to three of the most common causes of non-specific low back pain.
The term sciatica describes symptoms that are often felt traveling into the buttock, upper thigh or lower leg that cause pain, possibly numbness and tingling. If left untreated “sciatica” can also cause weakness, decrease deep tendon reflex responses and drop foot. Sciatica describes symptoms that root from the sciatic nerve, which originates in the lumbar and sacral plexuses; however, the proper term is called radiculopathy, which is more general in nature but is described by first naming the level of the injury such as L5 radiculopathy.
In order to fully understand what occurs with low back pain, a general understanding of anatomy is needed! In the normal spine there are five lumbar vertebra, which are numbered respectively from top to bottom. There also are five fused sacral vertebra. In between each lumbar vertebra exists an intervertebral disk, which is meant to act as a cushion for our vertebra to move on. First, locate the body of vertebra, spinous process, transverse process, intervertebral disc and spinal nerve. So now that we are done playing hide and seek, time to start learning about what’s going on with your back.
Typically, intervertebral discs, when injured, protrude in the posterior direction (towards the back of the spine), and more specifically in the posterior lateral direction (towards the back and side of the spine). Why? Because this is the weakest point of the intervertebral disc and because of the weight of the body of the vertebra causes increased pressure to the back of the disk when compressed during bending and twisting activities. Now, as you can see, the spinous process blocks the posterior aspect of the disk from protruding in that direction. So, as path of least resistance reins true, the disc protrudes (bulges or herniates) in the direction of the spinal nerves. Once an intervertebral disk is protruding and pressing on a spinal nerve, symptoms are often felt in accordance to the dermatome in which that spinal nerve is related. Dermatome is a fancy name for an area of tissue supplied by nerves from a single spinal root. Figure two displays Dermatome Man, and where symptoms may be felt from coinciding disk injuries. It is important to understand, that symptoms may not be cut and dry, multi-segmental injuries often occur, and symptoms may be felt in areas other than specified by this figure.
Sacroilliac Joint Dysfunction
Another common source of low back pain occurs at, you guessed it, the sacroiliac joint. The sacrum, as I alluded to earlier, is composed of five fused vertebra that support the lumbar spine. It is shaped like an upside down triangle and connects with the illium, or more commonly referred to as the pelvic bones. This joint is mobile in the sense that it has to rotate forwards and backwards during important lower body movements such as walking. However, this joint can be hypermobile (moves too much) or hypomobile (does not move enough) on both sides leading to symptoms of low back pain that typically do not radiate, but may refer pain down the effected side/leg. Other causes of SIJ dysfunction are associated with falls, miscalculating a step, and muscle imbalances from right to left, especially between the hamstrings and quadriceps musculature. Pain elicited by this joint is often unilateral pain located at Fortin’s finger point, but also may wrap around the pelvis towards the groin area secondary to the ring like nature of the pelvis (Figure 3). Another important tip in understanding your low back pain is that SIJ pain seldom refers pain upwards to the low back.
The piriformis muscle often gets a bad reputation for causing pain, but why? The piriformis muscle originates at the sacrum, levels S2-S4, and attaches to the greater trochanter of the femur. Its action is to externally or outwardly rotate the femur bone. The issue with the pirifomis is that for most individuals it is an inherently TIGHT muscle.
At this point, I need to stop and explain the difference between TIGHT and SHORT muscles, which are often interchanged although they shouldn’t be. TIGHT muscles are muscles that are knotted up, or contracted more than normal; these are muscles that are potentially in spasm. SHORT muscles are muscles that have an inadequate length, this may or may not have anything to do with how much spasm that particular muscle is in. The remedy for TIGHT muscles is relaxation i.e. Deep tissue massage or foam rolling. The remedy for SHORT muscles is stretching. Why does this matter? If a TIGHT muscle is stretched, it may be aggravated more, which often occurs with the piriformis musculature. Back to the problem at hand. The sciatic nerve, which we talked about earlier, runs close to and sometimes pierces through the piriformis (Figure 5). When this muscle is in spasm, it may interfere with the sciatic nerves mobility causing symptoms similar to that of radiculopathy.
How can I begin to eliminate my low back pain?
Exercise is a key component of your treatment plan with the occurrence of low back pain. The “core” is composed of a number of muscles, in which are not limited to the rectus abdominus (six pack ab muscles). Think of your core as a box, with a front, back, sides, top and bottom. Core muscles have been studied in patients with low back pain, and showed to atrophy very quickly, which is the reason physical therapists focus so intensely on them. While returning to function is important, we must first build a foundation, and that foundation begins with the most basic exercise that I often find cannot be completed and isolated by the majority of my patients. Repetitions and sets are not included in these exercises, as you should always consult with your medical professional prior to performing any exercise program.
Pelvic Floor Contractions (Kegels)
This exercise is performed by lying in the hook lying position. I like to cue my patients to perform by placing their fingers over their hip bones and rolling the tips of their fingers into their pelvic muscles. Kegels are performed by contracting the pelvic floor muscles, and the most easily described way to perform this exercise is to imagine urinating, and to squeeze as if to stop the flow of urine. This exercise should be held for a period of time (3-10 seconds) depending on tolerance and performed for sets of 3-5. Simply put, this exercises activates the bottom of the “core” and begins to strengthen muscles that aid in supporting the spine.
Now that you have mastered the pelvic floor contraction, it is time to start adding some movement into exercise and making the exercises a little more challenging. An isometric exercise is one in which your muscles are contracting but not moving through a range of motion. The muscles we will be activating here are, you guessed it, the adductors. The adductors connect to our pelvic bones, and are an important part of stability to our pelvis as we are moving, walking, etc. To begin this exercise, assume the hooklying position again. Place a small, un-weighted ball in between your knees, place fingers in the palpation position, activate your pelvic floor muscles, and finally squeeze the ball with your knees. Hold this position with the combination of the two contractions for 3-10 seconds and then relax all your muscles.
Similar to the adduction isometric, this exercise is performed in the hooklying position. Place a looped belt around your knees, place tension on the belt by pushing your legs apart and adjust the tightness of the belt. This exercise is performed by activating your gluteal muscles and pushing your legs out into the belt for 3-10 seconds before relaxing.
There have been a number of research articles written about the importance of the gluteal muscles in helping to resolve low back pain. Working to strengthen the posterior chain muscles (gluteals and lumbar spine muscles) can be done starting with this simple and effective exercise. Bridges are performed by starting in the hooklying position; Pushing through your heels, lift your backside off of the table and squeeze your gluteal, hold the top position for ~2 seconds before returning to starting position.
Abdominal isometrics begin to separate upper and lower extremity movements in a cross like pattern in order to activate stabilizing muscles that cross the pelvis. This exercise is performed with a physioball in the hooklying position. Place your elbows and knees on the ball, push into the ball with your left arm and right leg holding for 3-5 seconds, and perform on the opposite arm and leg.
For more information or to schedule a physical therapy or chiropractic evaluation, call our office at 201-746-6577. Your health is always our priority.