Chronic Low Back Pain With Frequent Episodic Flare-Ups

A clinical paradigm for treating chronic low back pain, with frequent episodic flare-ups, using a combination of: movement assessment; flexion/distraction mobilization; Active Release Soft Tissue Therapy and patient-focused corrective exercises along with pain coping strategies.

History

Our patient was a 48 year old, healthy and active, married professional woman. Other than her history of back pain, she denied any other significant health issues. Her history of low back pain began with an event 14 years before we saw her. She remembered bending forward to lift her child out of the crib when a sudden sharp pain occurred in her low back. She described sharp, shooting pains in her right leg and a very stiff and sore low back. Because of her parental obligations, she was unable to seek immediate care and just “dealt with the pain” for a few weeks. Ultimately that episode resolved, but she since claimed to always feel her low back pain to some extent and admitted to periodic, severe flare-ups about once a year. She also admitted that perhaps the flare-ups had of late become more frequent and more severe. She stated she was experiencing a very stressful time in her life because she and her husband—recently and reluctantly—agreed to a divorce. She also noted her high-stress career as a business owner with frequent travel and long hours. Before seeing us, she had varied and inconsistent therapy, including traditional chiropractic manipulative therapy as well as massage. She rated her pain an 8 that easily reaches a 10 during certain movements. The pain was constant in her low back, biased to the right side with intermittent sharp, shooting pain all the way into her right foot. Bowel and bladder functions were normal. Finally, she was distressed that her back pain prevented her from running, a form of stress relief she labeled her "therapy".

Exam

When she rose from a sitting to a standing position in the waiting room, her gait was slow and guarded and she presented with a mild antalgic shift to the left. When we eased her into a supine hook, lying with legs bolstered, she experienced immediate, mild relief. Muscle challenge revealed all strengths normal except for a slight sluggish response to right big toe resisted dorsiflexion. (Graded 4+) Plantar reflexes were normal, and deep tendon reflexes were normal except for a slightly hyper reaction to right patellar tap. Heel and toe walking was guarded but showed normal strength. Passive neck flexion was negative. Straight leg raise revealed a shortened hip flexion without neuro-tethering signs. She claimed a hyper sensory response to light touch at the distal right L4/L5 dermatome. Passive range of motion, muscle strength, and palpation (palpation exam was performed while tolerance testing on the flexion distraction table) revealed the following:

  • restricted and weak psoas, bilateral but more pronounced on the right;
  • strong contracture throughout the thoraco-lumbar fascia, lumbar erectors and sacral ligaments.
Deep palpation exposed a strong tissue contracture at the para-spinals along the L4-L5 segment. Hip exam revealed limited internal greater than external femoral rotation with a hard capsular end feel on the right and external greater than internal femoral rotation with muscular end feel on the left . Anterior to posterior femoral acetabular joint glide was restricted in right hip. Forced fl exion with adduction performed on the right hip elicited a sharp, deep and tender pain at the anterior capsule.

Diagnosis

Tissue diagnosis:

A chronic, moderate sprain with possible scarring and fi ssuring of the deep annular fi bers within the posterior right quadrant of the L4/L5 inter-vertebral disc, plus right hip capsulosis and tendonosis.

Functional diagnosis:

Constant lumbar sheering and right hip impingement as a result of a lumbo-pelvic hip asymmetry due to a repetitive movement disorder.

Treatment And Therapy

Because we recognized that her low back pain was not only a result of the functional and structural tissue insults but was also likely being amplifi ed by her excessive stress and current fear, we needed to ensure that our therapy was directed to both the tissues involved and the patient as a whole. For the sake of clarity within this case study, I will separate the explanations of the tissue work from the discussion of the whole-patient therapy but stress that they occurred simultaneously throughout each encounter using continual assessment and re-assessment, explanation, empathy and reassurance. We felt we could do as much with our words as with our hands.

Since our exam revealed:

  • a typical lumbo-pelvic hip asymmetrical scenario with her right asis drawn forward from moderate contracture within her right hip fl exor (illiacus, tfl and rectus) fascial complex and her right anterior hip capsule, while,
  • conversely, her left pelvis was torqued back from contracture within the gluteus maximus and medius, external hip rotators, and posterior hip capsule,

we hypothesized that this presentation was contributing to the constant sheering into the lumbar spine with the L4/L5 disc ultimately being the victim. (In a biomechanical sense, we considered the L4/L5 disc as the specifi c tissue that was least able to attenuate the sheering load) Tissue treatment was then fi rst directed towards the entire lumbo-pelvic hip complex to address the contributing factors.

To begin, we placed the patient prone with her right asis blocked by a wedge allowing the right anterior hip complex to be pushed back. Typically, a patient will express immediate relief, and such was the case with our patient. Because the relief was immediate, we could then consider that the LPH complex asymmetry was likely contributing to the back symptoms. We wedged the left thigh about 6 inches below the asis, allowing the left lumbo-pelvic complex to fall forward and thereby balancing out the LPH complex and gravitationally relieving some of the sheer forces on the sprained disc. Also, we applied moist heat to the low back spine. Now that the patient was comfortable, passively lying prone and blocked, we were able to spend a few minutes explaining her diagnosis, our therapy aims, our shared expectations and the likely prognosis. Th is can sometimes be the most important moment of the entire therapeutic relationship as it allowed us to connect and empathize with our patient. Aft er about 10 minutes, we were then able to begin the tissue work.

Before I describe the specifi cs of the tissue work, I want to stress the importance of the therapist’s presence. We have experienced that eff ective soft tissue work can best be achieved when the therapist is both focused and present, and demonstrating a precision of intent (What structure am I trying to eff ect? In what way and by what amount of eff ort? ) When it comes to the low back, we are attempting to improve the texture and physiology of some very strong, deep and dense structures and tissues. Th e only way to do so is to bring a lot of eff ort to the work.

For the patient in this case, we targeted specifi c Active Release Th erapy to the right illiacus/tfl rectus and fascia as well as the left hip capsule glutei fascia and Iliolumbar ligament. Following that, we targeted Active Release Th erapy to the psoas muscle bilaterally. Our specifi c intent was directed to the psoas muscle where it passes in front of the L4/L5 segment as a hard tissue texture or adhesion— something that is oft en felt at this specifi c segmental location in patients presenting with chronic lumbar disc sprains.

We addressed our patient’s right hip by fi rst doing a deep and specifi c ART release on the anterior hip capsule, hip fl exor tendon and related structures followed by an anterior to posterior accessory joint translatory and end range mobilization fi rst in distraction, then in neutral and fi nally with some mild compression. We initiated all these accessory movements from a closed pack position of fl exion and adduction just short of the impingement point.

Following the soft tissue work, we positioned the patient on the fl exion distraction table with the aff ected segment aligned slightly below the axis of table rotation. We tested the patient’s tolerance through slow, gentle table movement. Once we were satisfi ed she could tolerate it, we targeted tissue release therapy to the low back area starting superfi cial and then moving deeper. Superfi cial passes were intended towards the t/l fascia, superfi cial fascia erectors, sacral fascia and ligaments. We gave special attention to the t/l transitional segment because this area is oft en found to be tender and restricted with lower lumbar sprains. As the superfi cial tissue soft ened we were able to work deeper until the deep para-spinal structures (multifi dii, intertransversari, and facet capsules) were palpated and addressed. Quite oft en the exact area (usually unilateral, and not necessarily on the pain side) can be palpated as a dense, sometimes fi brous, always acutely tender, nodule. Th is was exactly what we found with our patient. With reassurance and a strong contact, we did 3-5 fi rm passes synchronized with the fl exion movement of the table in order to soft en the nodule and thereby release the tissue contracture that had trapped or congested the structures—the outer annulus; the local nerve and blood supply to the segmental musculature; and the blood supply to the nerve roots as they were caught in the reactive environment of the sprained disc.

Following the tissue work on the fl exion distraction table, we carefully repositioned the patient in a hook lying supine position to allow the disc pressure gradient to balance out and instructed her that this would be a good relief position to use at home.

As we proceeded through all the tissue work, we maintained a constant dialog with the patient, addressing the nature of her injury, and our expectations, in order to reassure her. Th is gave her an opportunity to give us feedback, discuss her fears and concerns, and ask questions about the prognosis. As we learned more about her and her lifestyle, we began to address how she moves through her life—specifi cally, how she gets up from sitting, how she gets in out of her car, how she bends forward–in general, how she moves. Th is was important because we believe the mechanism of injury was likely an accumulation and repetition of micro trauma, and such micro trauma happens throughout our daily lives. We also recommended that she begin a walking program that she could use in lieu of running. Our plan was to use a progression back to a running program as a functional measure of improvement. In the meantime, she could use her walking as her “therapy” because the ability for her to maintain an exercise program was critical on all levels of her care— in assisting in tissue healing; in allowing her to maintain personal control of her care; and also in providing her the therapeutic eff ect of an exercise program to help with her stresses.

Our patient responded moderately well to the fi rst visit, claiming about a twenty percent reduction in pain. Her gait was improved and before she left we advised her on how to move through her daily activities in ways that put the least amount of stress on her back. We instructed her to daily do the prone blocking with gentle gluteus contractures at home, paying close attention to how her back responded. We also advised her to get into the supine hook lying, bolstered, position as a relief strategy whenever possible. Because her gait was still guarded, we advised her not to begin her walking program immediately but assured her she would be able to begin quite soon. Since every situation is diff erent, and every treatment plan is customized, we establish frequency of therapy based on all the competing factors. In this case, we treated her twice in the fi rst week aft er her fl are-up and then scheduled two visits the following week.

Plan

Aft er the initial four visits mentioned above, her pain had been reduced by about 50% with her right leg 80 to 85% less symptomatic. Her symptoms had stabilized and her gait had improved enough that we suggested she begin her walking program as tolerated. As we considered the frequency of treatment, we needed to evaluate all the factors involved with her case. We felt we were able to do enough tissue work to nudge the healing eff ect and, considering her schedule and life stresses, we decided a more frequent treatment plan might have added yet another stressor on her schedule. Given the relief and reassurance she felt in the fi rst two weeks, she desired to continue therapy weekly on Fridays following her work week. She felt the Friday treatment gave her enough relief that she could continue to extend her walks on the weekends. Our patient has since maintained a wellness type of treatment plan in which she presents for wellness or preventative care about once every two or three weeks, a frequency based on her personal needs, requirements, time schedule and resources.

Prognosis

It has been three years since her initial presentation without an episode of severe pain. She still presents for wellness care periodically, with greater or less frequency depending on her schedule, symptoms and availability. During these visits we do the tissue work, she updates us on her exercise program—she does mostly long walks with periodic running—and if we have discovered new insights we share them with her. We continue to assess and refi ne her corrective, strength and stability exercises.

Discussion

Because chronic low back pain may be the end result of a variety of cumulative factors, all these factors should be exposed and addressed. First, with most patients, we have found that their individual coping strategies, or attitudes in relation to the pain and disability, need to be assessed and then addressed. Typically, this requires frequent and consistent reassurance that, despite the pain, their presenting injuries are actually likely less severe than what might be suggested by the intensity of the pain during a fl are-up or the persistence of the pain during a time of relative quiescence. Since all the therapists in our clinic have had the misfortune of experiencing severe and chronic back pain, we can employ the most powerful healing technique available to humans—empathy. We have found that empathetic communication with the patient promotes the most powerful connection we can make. Just by saying; “I have been there” opens up an empathic and compassionate level of communication. Th is is important because, once achieved, all subsequent dialog has more meaning and intimacy, allowing for better understanding and commitment from both the therapist and patient, i.e., a partnership has been formed.

Secondly—as mentioned above but worth repeating—the cause, or mechanism, of injury producing low back pain can usually be ascribed to cumulative and repetitive micro- trauma. It’s the repetitive daily stresses that continually sheer the soft tissue structures (most oft en the lower lumbar discs) that lead to the chronicity and periodic fl are ups of low back pain. Some of the intrinsic causal factors of this micro-trauma are:

  • direct; myofascial contracture and/or imbalance;
  • joint dysfunction;
  • neurological disconnect at the lumbo-pelvic hip complex (some of them potentially less direct);
  • foot stiff ness;
  • thoracic spine contracture or dural tensioning coming from cervical spine dysfunction;

as well such external factors as:

  • poor movement patterns;
  • postural unawareness; and
  • sustained poor movement patterns;
  • stress, fear and poor coping strategies.

We have found empirically that the benefi ts of focused, intent-full bodywork with frequent re-assessment helps expose the more infl uential underlying causes—be they intrinsic or extrinsic as identifi ed above—and therefore we are able to address these causes more effi ciently, our goal always being to minimize reactive symptom relief therapy and focus on a more proactive wellness type of therapy.

Our patient in this case presented with a typical direct intrinsic neuromusculoskeletal dysfunction that was likely contributing to her symptoms. Exam revealed moderate contracture in the right hip fl exor complex and posterior capsular contracture within the left hip.

Although our working diff erential diagnosis included the possibility of disc injury, we also needed to conceptualize a working functional diagnosis. A documented diagnosis is important for many, obvious, reasons:

  • accurate and fair insurance reimbursement;
  • better communication between providers of diff erent specialties , especially between Chiropractors and Orthopedists; and
  • patient education.

Also, a working functional diagnosis allows us to effi ciently target our therapy and bodywork directly to the source of the problem. Indeed, when it comes to our diagnoses, we need to speak two languages, one for documentation and communication and one for effi cient, targeted therapy.

By blocking our prone patient with the right ASIS elevated and the left thigh stabilized we were able to take out the torque from the pelvis that was contributing to the sheering at the L4/L5 disc. Furthermore, by having the patient posterior tilt, and then fi rmly contract the glutei, we were able to use the powerful glutei to begin to address the pelvic tilt by recruiting the glutei as powerful hip extensors. Assuming that glutei quiescence can be a musculoskeletal consequence of our modern life and movement patterns, we like the idea of practicing a strong neurological recruitment pattern that allows the patient a safe (lying prone) posture to retrain the neurologic pathway to the glutei to basically pull the torque pelvis back towards symmetry. Th en, as the patient demonstrates the ability to initiate this corrective exercise we can add progressions. Th e fi rst would be to train the patient to commence deep diaphragmatic breathing while in the contraction in order to synchronize deep breathing with glutei recruitment. Once a successful demonstration of the corrective exercise is done in the clinic, the patient can then be given blocks and instructed to do active self blocking at home with the frequency dependent on their degree of torque. Th e home-blocking exercise introduces to the patient the fi rst of what will be several exercises, movements and strategies to move towards an independence of reactive and episodic therapy and to the freedom of a proactive wellness plan.

Most hip impingements present with a conspicuous movement disorder which will be revealed with an adequate exam or assessment. Since a movement disorder is the primary culprit in contributing to the symptoms (in the case of our patient, pain and tenderness at the anterior hip crease), a targeted movement solution should be the most effi cient resolution. By introducing accessory joint movements to our patient’s right hip following the ART release work, we were able to quickly induce her right hip into a more func- tionally neutral position. Corrective exercises, including self-directed joint mobilizations, stretches and strengthening exercises were demonstrated and reviewed as our patient progressed through her care.

By using the fl exion distraction table in order to address the specifi c tissue at the site of the sprain we were able to focus our contact deep to the level of injury. Th e intent of the deep tissue release is to soft en the local tissues that have reacted to the sprain with muscle guarding and contracture. Th is contracture surrounding the disc, we feel, obstructs local blood fl ow and oxygen into the area while also obstructing the cell debris and waist product removal. Basically we look at it as stalled local physiology. By encouraging blood and oxygen into the local tissue and assisting the removal of stagnant waist product, we liken the work to decongesting the area. We feel that one of the more important patho-physiological consequences of the sustained tissue contracture is a progressively hypoxic environment for the local neurology and likely the nerve roots themselves. It may be that a hypoxic environment around the nerve root is as problematic as an infl amed nerve and this may be why we oft en see a sudden relief of nerve root symptoms aft er a specifi c deep release. It is oft en these same patients that have not responded well to NSAIDs. It may well be that local hypoxia rather than local infl ammation is the underlying patho-physiological phenomenon leading to pain and nerve irritation.

Our patient in this case has responded well, and continues to respond well, to the fl exion distraction mobilization therapy for her lumbar spine. Because of that success we have been reluctant to introduce side posture manipulative therapy. In many cases we will consider graduating a patient to lumbar CMT as many studies have shown unique benefi ts to the disc tissue with high velocity, low amplitude, rotary manipulations. If we were to move into the CMT for our patient’s lumbar spine, we would likely begin to introduce rotary forces on the appropriate motion segments based on our palpation fi ndings during the fl exion distraction therapy. Because, in this case, the patient has maintained a wellness program, we have had the opportunity to assess and manipulate other areas of her spine as she has certainly complained of and presented with fi xations within both her cervical and thoracic spine.

I believe one of the greatest benefi ts of a long-term wellness treatment plan is the opportunity for a continuous dialog and a constant refi nement and evolution of an exercise and lifestyle program. Rather than a static set of exercises (usually drawn in stick fi gures) that the patient adheres to (or not) for an indeterminate amount of time, I strongly feel that patients must participate in the continual refi nement and advancement of their programs. During wellness visits we ask what they have been doing, what they may have learned about themselves, and what refi nements they have discovered. We can then introduce and demonstrate other options for exercises and exercise tracts. In the case of the patient we have been discussing, she has continued her walking and running program during which she goes through a series of stretches, joint mobility drills, nerve glides or fl ossing, eye drills and strength exercises. Having her perform these exercises during her walks gives her a consistent template and feedback mechanism to work within, not to mention it’s free, self directed, outdoors and fun.

Further Discussion

Although in the above case our patient presented without hard neurological signs and her history and exam confi dently ruled out a potential pathological condition, there was some ambiguity with regards to imaging. Considering cost, inconvenience, radiation exposure and the potential for false positives, we feel it was appropriate to withhold imaging until a reasonable amount of conservative therapy was completed. However, this case may also have justifi ed an MRI exam of the lumbar spine in order to come closer to confi rming the working diagnosis. In cases where there has been a long chronicity of pain, with increasing severity of fl are-ups and deep fears related to the pain, I have seen full work-ups, including an MRI, be of signifi cant benefi t, if only because it assured the patient that all avenues were being explored. However, that said, it is our responsibility as clinicians to educate our patients about the relationship of radiological impressions and prognoses because there is a danger that patients receiving radiological reports will assume the identities of “bad backs.” It is here that all our knowledge, experience, empathy and reassurance come in.

Finally, I feel it is important, during the course of therapy, to discuss with our patients what other potential therapy options would have been available to them had they not come to us for care, especially if the patients are new to Chiropractic care. In order to do so, we must be aware and knowledgeable about what those other options are. It is my strong belief that a Chiropractor act as a primary care portal into the world of low back pain. Having discussions with patients about other options—what they are, what the consequences of those therapies could be, and when we would consider a referral—will oft en give the patients greater confi dence in our conservative approach. Having current knowledge of the common medications, physical modalities, different manual therapies, injections and potential surgical options used by the diff erent specialties for severe low back pain allows us to make educated decisions regarding patient care and reassures our patients that we are not treating them in a vacuum.

In conclusion, the above story of one patient with low back pain is unfortunately all too common. I highlighted her case because of the range of contributing factors that played a part in her prognosis. It is oft en very diffi cult, if not impossible, to determine what variables are contributing the most at any specifi c time in the history of the back pain. As described above, we feel we have structured a treatment paradigm through experience, continued didactic study and personal experience that has shown, at least empirically, to be successful most of the time. I feel this treatment paradigm has been successful mostly because, however seduced and dependent we have become in health care technology, we still need—perhaps more now than ever—skilled human touch, compassion and empathy to help us cure our own, as well as our patients’, ailments.