Download It Depends! A Holistic View to dealing with low back pain

IT DEPENDS! A HOLISTIC
VIEW TO DEALING WITH
CLIENTS WITH LOW
BACK ISSUES
PRESENTED BY:
BRIAN JUSTIN, MKIN, CEP, CSCS, NKT FMS, HLC2, CHEK-1
OBJECTIVES
• To view low back issues with the following perspectives:
• Visceral connections
• Nutritional connections
• Fascial connections
• Emotional Connections
• Postural connections
• Movement Connections
BACK FACTS
80% of the population will experience some form of back pain
at some point during their lifetime.
Back problems account for 40% of all work days missed due to
injury or illness.
Backache is second only to headache as a common medical
complaint.
Most back and neck pain stems from lifestyle choices or life
experiences.
VISCERAL CONNECTION
ORGAN HEALTH: VISCEROSOMATIC
REFLEXES
Visceral sources of pain include
the internal organs and the
heart muscle.
Visceral pain is not welllocalized because:
1. Innervation is
multi-segmental. (See next
slide)
2. There are few nerve
receptors in body organs.
Therefore the pain is poorly
localized and diffuse.
Even
Chuck Norris
is concerned
VISCEROSOMATIC
REFLEXES CONT.D.
Visceral pain refers out due
to:
a. Visceral nerve fibers
synapse at the level of
the spinal cord close to
the fibers that supply
somatic structures.
Eg. Pain of cardiac or
diaphragmatic origin is
often experienced in the
shoulder because the C5-6
spinal segment (shoulder)
also supplies the heart and
diaphragm.
VISCEROSOMATIC
REFLEXES CONT.D.
B. Viscera have few
nerve endings and
visceral pleura are
insensitive to pain.
It is not until the organ
capsule is stretched
(tumor or inflammation
and distention) that
pain is perceived.
VISCEROSOMATIC
REFLEXES CONT.D.
It does get complex:
Somatic-somatic reflexes (a bruise on the
leg causes knee pain).
Somato-visceral (biomechanical
dysfunction of the 10th rib can cause gall
bladder changes).
Viscero-viscero (pain in one organ causes
symptoms in another organ – eg. client has
chest pain – normal cardiac findings
(“heart’s fine”) – problem maybe gall
bladder as it originates from the heart
embryologically and cause cardiac changes
and shoulder pain). This may be it. BUT:
Doctor may do a gall bladder exam and find
nothing! HUH! WTF! Chest pain could be
from arthritic changes in cervical spine as it
shares common sensory pathways with the
heart (C3 to spinal cord)
Your nervous system receives
input from all over. Usually
accompanied by ANS changes in
vital signs, unexplained sweating,
and skin pallor – associated signs
and symptoms.
VISCERAL PAIN
REFERRAL PATTERNS
Systemic issues
show up as
constant pain.
Some questions to
ask:
Are you having any pain
anywhere else in the body?
Are you having symptoms of
any other kind that I should
know about? (i.e. digestive
issues?)
Small intestine
(T7-10)
Large intestine
(T11-L1)
Liver
(T5-T9)
Stomach
(T6-10)
Mid Thoracic spine
and umbilicus
Lower abdomen
Lumbar spine
R. T- spine
R. Shoulder
Upper abdomen
Thoracic spine
ORGANS TALK TO
MUSCLES
External oblique – T7-12
Internal oblique – T7-L1
TVA – T7-L1
Rectus Abdominis – T5-12
Chek, 2004
AS A KIN WHAT CAN
YOU DO ABOUT THIS?
Don’t throw up your
hands and say, “ well I
am not a Doctor, so what
can I do about it?”
Just be the identifier.
Many people do not see
their medical provider
for symptoms.
Before you load them up
with training, if you
identify something
better to have it checked
out.
Quick Screen
A. Past medical history (can
be done on your
intake/client history form).
B. Risk Factor Analysis
C. Signs and Symptoms.
D. Measurements
A. PAST MEDICAL
HISTORY
PAR-Q and Client History
Family and/or previous history of
disease (list out the common
illness).
Psychosocial:
- recent travel over seas
-occupational/environmental
exposure
- Medication usage
Women: Pregnancy
Current complaints (if any)
B. RISK FACTOR
ANALYSIS
Age
BMI
Gender
Substance/Use and Abuse
Race/ethnicity
Tobacco use
Sedentary lifestyle
Domestic violence
Exposures of any sorts
C. SIGNS AND
SYMPTOMS
Blood in urine, stool, vomit, mucus
Client may have filled this out on your
client history form.
Difficulty chewing/swallowing/speaking
But always ask the question:
Dribbling or leaking urine
Are there any symptoms of any kind
anywhere else in your body?
Fever, chills, sweats (day or night)
Include the list to the right on your
client history form as well.
Heart palpitations or fluttering
Use a review of systems in your client
interview. If your client out pours
symptoms they have been going
through you can see if there are
clusters indicating a systemic issue.
If so, recommend a check up if you
have concerns. Do not tell your client
what you think as you are not a
diagnostician and is out of your
scope of practice just say, “based on
what you have told me I would like
you to talk to your doctor regarding
these symptoms”.
Memory loss
Changes in bowel or bladder
Confusion
Cough
Dizziness, fainting, blackouts
Headaches
Joint pain
Nausea, vomiting, loss of appetite
Numbness or tingling
Problems seeing or hearing
Skin rash or other changes
Sudden weakness
Swelling or lumps anywhere
Trouble breathing
Trouble sleeping
Throbbing sensation/pain in bely or anywhere else
Unusual fatigue, drowsiness
D. MEASUREMENTS
Blood pressure
(< 144/94 mmHG)
Resting Heart Rate
(< 100 BPM
Resting respiration
(rate (10-14) and quality
(2/3rd diaphragm and 1/3
chest))
NUTRITION CONNECTION
Hierarchy of Health from
the Ground up (Fors, 2007)
Healthy mind/body/spirit
Organ Systems
Tissues
Cells
CHO, PRO, FAT, and Vitamins
Earth elements (Hydrogen, etc.)
Minerals and trace minerals
Earth and its atmosphere
NUTRITION’S
CONNECTION
Food intolerances/Quality
Gluten and dairy – may lead
to visceral stiffness/bloating
leading to core muscle down
regulation
Artificial sweeteners are
implicated in systemic
causes of joint pain
(Goodman& Snyder, 2007).
Of course – quality of food
dictates how strong their
connective tissue will be.
Disc and hydration.
Some people think this
is a breakfast food!
NUTRITION’S
CONNECTION
Digestion
Dysbiosis (bad bacterial growth in
lower G.I. tract) is linked to chronic
pain and disease (fibromyalgia –
Pimentel, et al, 2004).
Dysbiosis increases permeability of
the small intestine leading to allergies
due to absorption of partially digested
proteins then spurring on
inflammation and with this comes
achiness, fatigue, and headaches.
Toxins
All human beings today store toxins
in their tissues.
Bell et al (1998), show that low levels
of environmental toxins in tissues
can cause muscle pain.
How?
Liver becomes overburdened and
cant keep up with the demand.
Toxins act like free radicals and
accumulate in tissues leading to
inflammation and oxidative stress.
This leads to painful, stiff and easily
fatigued muscles (energy production
in tissues affected by above). (Fors,
2007)
Vulnerability is based on your
client’s biochemical individuality.
STEPS FOR THE KIN
TO HELP CLIENTS
1.
Diet logs (2 weekdays and 1
weekend day)
2.
Analyze the number of
chemical sources in their diet.
3.
Help make better lifestyle
choices.
4.
Assess digestion.
I use this questionnaire from Paul
Chek’s excellent manual, How to
Eat, Move, and Be Healthy.
Scores:
50-130 – High Priority to look into.
30-49 – Moderate priority to look into
<30 – Low priority to look into
Your nervous system will make
adjustments to body systems based on the
inputs it gets! This will reflect in movement
competency and capacity
POOPIE LINE UP – CHECKING
YOUR DIGESTION
From right to left
-Poopie policeman (healthy poop)
– formed, passes easily, light brown,
smells earthy not foul, and floats.
- Flasher – undigested food
particles.
- Diarrhella – body’s attempt to
detoxify.
- - Pellet man- altered states of
peristalsis and dehydration
- Pellet Man – may indicate
altered states b/w peristalsis of
the colon and dehydration
- Bodybuilder – too much
dehydrated foods such as
protein powders – hard to pass
- Olympic swimmers –
undigested fat (insufficient bile)
– hard to flush.
- Mr. Sinker and Stinker –
processed foods, medical drugs,
and environmental toxin
exposure
From: Paul Chek, HHP, NMT – How to Eat,
Move, and Be Healthy
FASCIAL
CONNECTIONS
Slings:
• Thoracolumbar Fascia System (TLF)
- Latissimus Dorsi – Gluteus Maximus Link
- Obliques – Transversus Abdominis Link
- Erector spinae – Multifidus Link
• Fascia Lata System
- Gluteus Maximus Link
- Quadriceps – Hamstring Link
Abdominal Fascia System
- Rectus abdominis – Obliques/Transversus Link
- External oblique – Pectoralis/Serratus Anterior Link
- Shoulder girdle – Abdominal Mechanism Link
THORACOLUMBAR FASCIA SYSTEM
•
•
•
•
•
•
Dense 3 layer tissue network that extends from the sacrum to the upper
back and neck.
Prominent in low back.
Posterior layer is strongest and thickest and is the only layer in the
thoracic region.
Transmits forces from shoulder, lumbar spine, pelvic girdle, and
lower extremity.
Encloses ES, QL, and MF.
Anterior layer becomes thicker cranial ward and attaches to diaphragm.
TLF – MUSCLES THAT
ATTACH
•
•
•
•
•
3 layers merge to form
attachment point for the EI, IO,
and TVA.
LD-GM Link
Each muscle individually can
increase tension on the TLF.
Cinching of the TLF by these
two muscles stabilize lumbar
spine over multiple segments
decreasing translatory motion
(Porterfield and DeRosa,
2007).
This fascial complex crosses
the upper sacrum increasing
sacrum-ilium compression =
decrease in shear loads.
TLF – MUSCLE THAT
ATTACH
Oblique-TVA Link
• Attach at the lateral raphe
(junction between posterior
and middle TLF layers).
• TVA – influences all lumbar
levels.
• IO – Primarily influences lower
lumbar levels.
• EO – Primarily influences
upper lumbar levels.
• TVA and IO have a strong
attachment to the middle TLF
provide a nearly direct pull to
the lumbar transverse process
providing excellent segmental
stabilization in frontal and
transverse planes.
TLF – MUSCLE THAT ATTACH
Erector – Multifidus
• Deep ES attaches to the
transverse processes of lumbar
vertebrae.
• ES aponeurosis (which attaches to
the ilium and sacrum) allows the
thoracic ES to act over the lumbar
spine which causes an extension
moment (by moving the thorax
posteriorly) and compressive load
to the lumbar spine.
• ES aponeurosis also exerts a
nutation (flexion)moment on the
sacrum = increase tension on the
key ligaments (sacrotuberous,
sacrospinous and interosseous)
increasing stability.
TLF – MUSCLE
ATTACHMENTS
•
Due to the ES anterior
attachment to transverse
process it checks anterior
shear of lumbar vertebrae.
•
In concert with the psoas
forms an anterior-posterior
guy wire contributing
compression and providing a
dynamic restraint to antpost. shear stress.
TLF MUSCLE ATTACHMENTS
• Multifidus act over lumbar segments in compression rather
than torque.
• Contraction of ES and MF increase tension via a
broadening effect.
• Atrophy (seen in low back pain) in MF contributes to loss of
stability and fascial tension generating ability.
• According to Daneels (2001), an effective training stimulus for
MF atrophy is dynamic motion of the spine against resistance
combined with static hold between concentric and eccentric
contractions.
FASCIA – LATA
SYSTEM
• The fascia-lata system is a strong
network of connective tissue that
surrounds the thigh musculature –
thickest at IT band.
• Quads/Adductors/Hamstrings
• Biceps femoris - Deep longitudinal
system.
• Glute max links the TLF system
with the FL system. Contraction or
stiffness of glutes results in
enhanced tension of these 2
important fascial networks that
span the lumbar spine, sacroiliac
joint, and hips.
ABDOMINAL FASCIAL
SYSTEM
• Abdominal fascia is the
aponeurosis (apo) of the EO, IO,
and TVA and the rectus sheath of
the rectus abdominis.
• Works like the TLF for the front.
• EO, IO, TVA increases tension in
the same way LD-GM does to
the TLF.
• Below the umbilicus – All 3
muscle’s apo passes anteriorly to
RA countering anterior shear
stress of lumbar spine and ab
viscera. This aids the increase in
lordotic angle at L4-L5 & L5/S1.
ABDOMINAL FASCIAL
SYSTEM
• Obliques attach at the
tendinous intersections of
the RA allowing rectus to
function segmentally.
• TVA cinches the abdomen
in a corset like effect
creating another anterior
shear check.
• IO through the TLF
stabilizes lower lumbar
segments and the inferior
portion of the muscle
influences the pelvis
compressing pubic
symphysis which is
assisted by the hip
adductors also increasing
compression.
SHOULDER GIRDLE TO
ABDOMINAL MECHANISM
• Rhomboid major/minor
attaches from thoracic spinous
process to the scapula where
it links with the serratus
anterior. This then links with
the EO and then the
contralateral IO making a
continuous sling from the
shoulder to abdominal wall.
SO WHAT DOES ALL
THIS MEAN?
• Sometimes isolated work is
necessary to revascularize or
hypertrophy a muscle.
• But our bodies are an
integrated system, so using
multiple muscle groups and
motor patterns through muscle
slings and anatomical linkages
that tie the pelvic and shoulder
girdles to the spine should be
the training focus.
• Biotensegrity
• Anatomy Trains
• Who is the back picking
up the slack for?
STRESS CONNECTION
(STIFFNESS)
See diagram to the right.
How does this affect your
quality of movement during
training?
Last nights fight with the girl or
boyfriend may elicit a different
movement strategy in your
client.
Habitual hyperventilation
(breathing problem) can trigger
anxiety/stress (Chaitow, 2008).
Depending on the degree of
stress produced it can
decrease mobility of the
vertebra (Schafer, 1987).
Stress
Sympathetic Activation
Sends out TGF-beta-1
cytokine to elicit an
immune response
1. Immune system – T3
2. Myofibroblast activation
(increases fascial stiffness)
ANXIETYBREATHING
STRESS AND KNOTS
Recurrent physical (injury/ergonomics), chemical
(nutrition/toxin), or emotional stress causes
muscle fiber contraction.
Prolonged contracted muscle fibers squeeze out
blood reducing ATP to cells.
Poor energy levels do not allow muscle fibers to
relax.
Creates a self-perpetuating taut band.
Any more added stress causes the formation of
pain-causing neuromyofascial lesions with
abnormal nerve endings.
These abnormal nerve endings is what creates that
painful trigger point!
They will alter your movement patterns.
Think of the following:
Physical – The obsessed runner who runs through
pain daily!
Chemical – The client who has a chronic poor diet
full of toxins and deficiencies.
Emotional – The person with job dissatisfaction.
You don’t see these clients do you? ☺
WHAT IS A KIN TO
DO?
Assess stress via Fantastic Lifestyle
Questionnaire or other.
Implement stress management
coaching
Teach myofascial release techniques
they can do at work and home.
Incorporate myofascial release
techniques as needed before
training.
Calm your client down with some
play as a warm up! Lets try one now:
ANIMAL MAGNETISM. (Forencich,
2010)
POSTURAL CONNECTION
Strong abdominals
and flexible hip
flexors keep the
pelvis neutral and
the body in
alignment
LUMBAR HYPER-LORDOSIS
Pathology
Weak abdominals
Implications:
and short hip
• Highflexors
contacttip the
pelvisin forward and
pressure
facetincrease
joints. back
strain
FLAT BACK
POSTURE
Weak:
Hip flexors
Erector spinae
Tight:
Hamstrings
Glutes
Abdominals?
Pathology
Implications:
Poor lumbar spine
mobility
Disc herniations
SWAY BACK POSTURE
Pathology Implications:
Body hangs on
hip ligaments and
anterior hip
structures
Kyphosis is
longer and may
extend into
lumbar spine
Disc injuries
MOVEMENT CONNECTION
Assess the client’s movement
Tools:
•
Functional Movement Screen
•
The FMS is a ranking and grading
system that documents 7
movement patterns that are key to
normal function. By screening these
patterns, the FMS readily identifies
functional limitations and
asymmetries. You will gain
knowledge on the stability, mobility,
balance, and injury risk of your
client.
•
Core stability is movement
pattern specific.
•
Movement Competence – Kelvin
Giles
•
Gait Analysis
•
SFMA
K. GILES – PHYSICAL
COMPETENCE
• Physical Competence testing is for
the purpose of establishing the
athlete/client’s training age and
trainability across a wide range of
movements.
• Data from the competency tests
will also form the detail from which
the initial training programs will be
determined.
• It shows the competence in
controlled movement rather than
the amount of weight carried or the
speed of movement.
• Very useful for tracking movement
improvement from a qualitative
perspective but given in a
quantitative manner.
Gait
Movement Pattern
Compensations
Associated Tests
Patellar
line drops
inside 2nd
toe
Adductor length
Gluteus maximus
strength
Gluteus medius
strength
Ant. Tibialis strength
Post-Tibialis Strength
This is a quick gait analysis.
Unequal
stride length
Achilles line
drops in.
Ant. Tibialis
strength
Post. Tibialis
Strength
Big toe
extension
Thomas Test
Straight leg
raise
Arm swing
inadequate
Trendelenburg
Sign.
Habit
Or ask if there
is a previous
shoulder injury.
Add in dorsiflexion
test/big toe mobility here
too!
Gluteus
medius
strength
IMPORTANT MOVEMENT’S TO CLEAR
FOR PEOPLE WITH LOW BACK
ISSUES
Ankle dorsiflexion
Hip mobility
Thoracic spine mobility
Big toe mobility
Important to attain mobility in
order to get some stability
(although some practices
challenge this concept)
Hip Mobility Test
Example
Thoracic mobility tests
example
CORRECTIVE APPROACH
(COOK, 2010)
Corrective Strategies Approach:
1. Attain mobility first (Passive/Active/Assistive) – this allows more
opportunity for sensory input therefore more information for the
brain to coordinate stability.
The recipe for the brain to make stability (Cook, 2010):
a. Structural integrity – pain-free structures without significant
damage, deficiency, or deformity.
b. Sensory integrity – uncompromised reception and integration of
sensory input.
c. Motor integrity – uncompromised activation and refinement of
motor output.
d. Freedom of Movement – mobility adequate to perform within
functional ranges and achieve appropriate end ranges and structural
alignment.
2. Lock in Stability if improvement in mobility occurs from number 1.
CONDITION FOR WORK AND
SPORT ENVIRONMENT
The 5 Stages of Building the Ultimate Back – Stuart McGill
Stage 1 – Groove Motion/Motor Patterns and Corrective
Exercise
Identify disrupted motor patterns (assessment)
Which movements produce pain? Why? – Avoid them.
Neutral spine awareness (or modified neutral spine
depending on condition), breathing, abdominal
bracing ability, & hip hinging mastery,
Train off your butt and train your butt! (bridging, ½
kneeling, “potty” squat, single leg activities).
Develop Fundamental or Primal Movement Patterns
(Squat/Lunge/Bend/Push/Pull/Rotate/Gait)
Muscle Balance esp. T-spine and Hip Mobility/Ankle
dorsiflexion
CONDITION FOR WORK AND
SPORT ENVIRONMENT
Stage 2 – Build Whole body and Joint Stability
The Big Three – McGill Curl, Side Bridge, and Birddog.
Build on the Fundamental Patterns.
Balance Training (can do daily) – discs, small muscles,
and ligaments play apart in position sense to activate key
muscles in stabilization (Jemmett, 2003)
The Anti - Exrflex
Stage 3 – Increase Muscle Endurance
Russian Reverse Pyramid for Endurance Training
Various options for exercises here depends on client
needs.
CONDITION FOR WORK AND
SPORT ENVIRONMENT
Stage 4 – Increase Strength
Definitely no “one-size-fits-all” process here.
Master body weight movements first. i.e. push ups
before presses.
Train the lats! – Remember the TLF system?
Stage 5 – Power
Power is developed in the extremities and
transferred through the core! Efficient and effective
power transfer through the torso requires spine
posture control, spine stiffness and stability, and
strength.
Do not train spine power. Train power at adjacent
joints!
TECHNIQUE AWARENESS IN AND
OUT OF THE GYM!
Consider tissue tolerance – Educate your clients on proper
posture and ergonomics. Poor movement and positioning
during the day (ie. how they sit at work) reduces tissue
tolerance which increases risk of breakdown.
Make cognitive association about how alignment during
exercise carries over to real life and vice-versa.
McGill (2007)
J. LEVINE – N.E.A.T.
C. HALLFORD – D.A.M.S.
Non-exercise activity thermogenesis
• Don’t be sentenced to the chair! It
kills the back!
• Get clients to move as much as they
can.
DAMS – Daily Activity Modifications
• They are used to teach the body how to
move more efficiently and decrease
wear and tear esp. for injured clients.
• An example: Hip hinging before lifting
something out of the trunk of your car.
• Do as often as possible!
• Cognitive Association!