The origin of chronic non-specific low back pain is difficult to determine, at least some seem to think so. So much so, the current trending understandings have almost given up on the mechanistic injury model and believe the source to be coming from the brain with the fear avoidance model leading the charge.
However, what we do know regarding the spine’s bending movements is that when the individual vertebrae do not motion share in a smooth way, this can indicate instability. These abnormal movements (when one vertebra moves out of its sharing path) are used by spinal surgeons to identify spinal levels of pain so they can be more precise on the surgical level. The imaging techniques that have historically been an asset to ‘pull-out’ these abnormal motion areas have included end-range load-bearing x-ray. Even though this modality has been useful, researchers are now turning to dynamic real-time fluoroscopy to help assess the quality of motion.
In a recent paper published by Breen
Their objectives were three-fold:
- Could they determine a biomechanical marker for low back pain?
- Could they find that load bearing played a contributing role?
- Could they determine a relationship between motion sharing of vertebral motion segments, age and disc degeneration?
The importance of this paper should strike at the core of all manual therapists who treat spine. As one of those, I find it kind of interesting that we have not taken the time to use our motion palpation skills to look for subtle moments that are painful for the patient. One of the assessment tools I use is to observe the presenting movement quality carefully. This often begins by watching how a patient gets out of a chair after a period of static sitting as it can tell me a lot about a patient’s spine.
In 2008, I was lucky enough to work with a well recognized and very well-respected spine researcher at the University Hospital of Aberdeen, Scotland: Dr Francis Smith. He was kind enough to take on my research project and gave me the use of his upright MRI research center to evaluate subtle spine changes. After collecting data from subjects who sat in a sustained position for fifteen minutes and then subsequently performing chair-care exercise 3 I was amazed how much the spine dynamically compressed and decompressed in the upright position. This type of study was never investigated before in this context, and it provided me with a whole new appreciation for subtle intervertebral disc changes.
With this new appreciation of the spine’s dynamics, I began to look at subtle movements more seriously in both the evaluation and treatment of spine as a chiropractor within my practice. Today, I use simple techniques of pressing onto specific landmarks while the patient is prone (for the lumbar and thoracic spine evaluation) always asking if patients feel a sense of discomfort at local or distal regions of the spine. When evaluating the neck (I find it best if the patient is supine and in a similar fashion with a much scaled down version of force), I will do the same; always asking the patient for their sensitivities.
I think what has helped me as chiropractor too is the other job I have which is crafting spine models. On my off-days, I play with real bones, which involves reconstructing the soft tissues that hold each vertebra together. I have a passion for communicating pain education to patients so they can get a grip on what’s ailing them which in turn, provides them with a sense of control and the ability to understand which movements can harm and importantly heal their spinal structures. It is often the subtle movements that cause pain, and if a low back pain patient can see the quality of their movement and the cause of it, they can work to improve it.
Returning to the study by Breen, they found abnormal movements (or motion sharing) with spine bending is more likely in those with low back pain. This is a big finding because they have shown with their results that there seems to be a cause from the spine not moving correctly. They also found that disc degeneration (which is most often indicated as disc height loss) was related to the abnormal motion sharing and looked to be related to pain.
- Alan Breen; Alexander Breen. Uneven intervertebral motion sharing is related to disc degeneration and is greater in patients with chronic, non-specific low back pain: an in vivo, cross-sectional cohort comparison of intervertebral dynamics using quantitative fluoroscopy. Eur Spine J 24 May 2017 DOI 10.1007/s00586-017-5155-y ↩
- Mellor FE, Thomas P, Thompson P, Breen AC (2014) Proportional lumbar spine inter-vertebral motion patterns: a comparison of patients with chronic non-specific low back pain and healthy controls. Eur Spine J 23:2059–2067. doi:10.1007/s00586-014-3273-3 ↩
- Jerome C.J. Fryer, Jeffrey A. Quon, DC, Francis W. Smith, MD. Magnetic resonance imaging and stadiometric assessment of the lumbar discs after sitting and chair-care decompression exercise: a pilot study. The Spine Journal 10 (2010) 297–305 ↩