10/8/2015. FACTORS IN BACK PAIN introduction 27% Framing the Discussion from a Clinical and Anatomical Perspective

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1 FACTORS IN BACK PAIN Framing the Discussion from a Clinical and Anatomical Perspective A B M P B a ck Pa i n S u m m i t With Clint Chandler FACTORS IN BACK PAIN introduction Back pain affects 8 out of 10 people at some point in their lives Migraine Pain 15% Neck Pain 15% Back Pain 27% Facial Ache or Pain 4% 1

2 Americans spend at least $50 billion each year on back pain 31 million Americans experience low-back pain at any given time Most causes are mechanical and not caused by a serious pathology Low back pain is the leading cause of Years Living with a Disability in 45 of 50 developed countries 2

3 Massage Therapy Makes a Difference! Part1: The Dynamics of Soft-Tissue Injury This Session Part 2: Back Pain The Big Picture Part 3: Treating Non-Specific Low Back Pain PART 1: THE DYNAMICS OF SOFT- TISSUE INJURY 3

4 Forces that Load Tissue Tissue Deformation Part 1: The Dynamics of Soft- Tissue Injury Tissue Strain Mechanical Strength Factors in Tissue Failure and Tissue Damage TISSUE LOAD The amount of stress soft-tissue structures are under due to forces FORCES A force is something that causes the movement of the body to change or body structures to deform 4

5 FORCE Body Tissue Tissue Load GRAVITY TENSION TORSION COMPRESSION SHEAR BENDING FRICTION Adductor longus Adductor magnus Erector spinae group Gastrocnemius Hamstrings Iliopsoas Levator scapula Gravity Pectoralis major Piriformis Quadratus lumborum Rectus femoris Soleus Sternocleidomastoid Upper trapezius DISTORTED POSTURE Displaced Center of Gravity Hypertonic Postural Muscles 5

6 COMPRESSION A force in which the tissue is loaded when structures are pressed together Example: Football players collide; contact at the crown of the head causes the cervical spine to be compressed between the head and torso TENSION (Tensile Force) A force in which the tissue is loaded when two ends of a structure are pulled apart 6

7 Example: If the tensile force exceeds the strength of the soft tissue structure and its ability to elongate, tears or ruptures result in the structure SHEARING A force in which parallel forces that act perpendicular to a structure load the tissue by creating tensions that pull in opposite directions Example: A headforward position causes shear stress in the lower cervical vertebrae 7

8 TORSION A twisting force (also called torque) that occurs along a shaft or axis Example: Asymmetrical contractures of the muscles on either side of the spine can cause torsion in the spine in which vertebrae rotate slightly in opposite directions Shoveling snow: The spine is flexed and rotated placing both shearing and torsion loads on the spine 8

9 BENDING A force where the inner surface experiences compressive force while the outer surface experiences tensile force causing a structure to bend Example: Spinal deformities like scoliosis displace the vertebral discs in a way that subjects the body to constant bending forces FRICTION A low magnitude force where resistance is created when one structure of the body contacts another as the structures move in opposite directions 9

10 FORCE Body Tissue Tissue Load GRAVITY COMPRESSION TENSION SHEAR TORSION BENDING FRICTION Forces that Load Tissue Tissue Deformation Part 1: The Dynamics of Soft- Tissue Injury Tissue Strain Mechanical Strength Factors in Tissue Failure and Tissue Damage Tissue Deformation: The change in shape a tissue undergoes when subjected to a load 10

11 TISSUE STRAIN The amount of deformation experienced by the tissue TENSILE LOAD TENSILE STRAIN COMPRESSIVE LOAD COMPRESSIVE STRAIN 11

12 Mechanical strength: The amount of force a tissue can absorb or resist before failure TISSUE FAILURE When a tissue is deformed by a load past the point where it can absorb or resist and breaks down FACTORS IN TISSUE FAILURE LOCATION RATE DURATION MAGNITUDE DIRECTION FREQUENCY POSITION 12

13 LOCATION Where is the force applied? MAGNITUDE How much force is applied? RATE How quickly is the force applied? 13

14 DIRECTION & POSITION Where is the force directed and what position is the body in when it experiences tissue loading? DURATION Over what period of time is the force applied? FREQUENCY How often is the force applied? 14

15 FACTORS IN TISSUE FAILURE LOCATION MAGNITUDE RATE DIRECTION POSITION DURATION FREQUENCY TISSUE DAMAGE When tissue is deformed (strained) by loads (forces acting on tissue) past the point where it can absorb or resist the load (stress), it fails, and tissue damage results Part 1: The Dynamics of Soft- Tissue Injury Forces that Load Tissue Tissue Deformation Tissue Strain Mechanical Strength Factors in Tissue Failure and Tissue Damage 15

16 Part1: The Dynamics of Soft-Tissue Injury This Session Part 2: Back Pain The Big Picture Part 3: Treating Non-Specific Low Back Pain Conditions that Cause Back Pain Part 2: Back Pain - The Big Picture Structures That Fail Back Pain Tissue Failure Scenarios CONDITIONS CAUSING BACK PAIN Back sprain Back sprain Discogenic low back pain Lumbar facet joint pain Mechanical low-back pain Non-specific low back pain Sacroiliac joint dysfunction Sciatica Scoliosis Spinal stenosis Spondylolisthesis Terminology related to back pain can be confusing! 16

17 RISK FACTOR Risk factors are particular internal and external conditions that increase the potential for an injury to occur Risk factors influence the mechanical strength of the tissue and its ability to resist a load without failure, and the frequency with which the body is exposed to loads that could cause tissue damage RISK FACTORS THAT INFLUENCE BACK PAIN: RISK FACTORS YOU PROBABLY CAN T CHANGE Being 50 or older Being male Having a family history of back pain Having spine problems since birth Having a history of back injury Being pregnant RISK FACTORS YOU PROBABLY CAN CHANGE Weak muscles and lack of flexibility Smoking Excess body weight Poor posture Stress and emotion Working conditions Conditions that Cause Back Pain Part 2: Back Pain - The Big Picture Structures That Fail Back Pain Tissue Failure Scenarios 17

18 STRUCTURES THAT FAIL BONES LIGAMENTS MUSCLES CARTILAGE DISCS NERVES WHEN BONES FAIL Pars Interarticularis Spondylolysis Spondylolisthesis 18

19 Ostephyte WHEN CARTILAGE FAILS 1 Collagen fibers break 2 Proteoglycans depleted 3 Cartilage softens and thins 4 Facet joints become misaligned 5 Bone on bone contact 6 Osteophyte formation WHEN LIGAMENTS FAIL Sprains are defined as ligament failure caused when fibers are overstretched or torn due to traumatic or repetitive loads that twist a joint, or force a joint to move beyond it s normal range of motion 19

20 WHEN LIGAMENTS FAIL THICKENING OF LIGAMENTS HYPERMOBILITY SACRAL ILIAC JOINT DYSFUNCTION 20

21 WHEN DISCS FAIL - Degenerative Disc Disease Disc Herniation WHEN MUSCLES FAIL 21

22 Quadratus Lumborum (QL) Erector Spinae WHEN NERVES FAIL 22

23 SCIATICA PIRIFORMIS SYNDROME BACK PAIN: It is likely that multiple tissues are being overloaded and failing to varying degrees at the same time 23

24 STRUCTURES THAT FAIL BONES CARTILAGE LIGAMENTS DISCS MUSCLES NERVES Conditions that Cause Back Pain Part 2: Back Pain - The Big Picture Structures That Fail Back Pain Tissue Failure Scenarios A Traumatic Event 24

25 Motor Control System Caught Off Guard Cumulative Trauma from Small Loads Part1: The Dynamics of Soft-Tissue Injury This Session Part 2: Back Pain The Big Picture Part 3: Treating Non-Specific Low Back Pain 25

26 Non-Specific Low Back Pain Defined Part 3: Treating Non- Specific Low Back Pain Red Flags During the Health Intake Process Treatment Goals Video Demonstration Non-specific low back pain is pain that is not attributed to a recognizable pathology It is pain associated with muscle strain, muscle tension, sprain, hypermobility, or joint fixation It is highly responsive to massage therapy intervention Where is the Low Back? 26

27 Red Flags When Evaluating Low-Back Pain Unresponsive Fever with Back Pain Significant Recent Trauma Significant Recent Trauma 27

28 Pronounced Numbness and Prickly Tingling Loss of Bowel or Bladder Function Medical history of cancer, suppressed immune system, osteoporosis, or chronic steroid use 28

29 Treatment Planning for Non-Specific Low Back Pain Acute Sub-Acute Chronic Injury up to 6 Weeks Pain, achiness, burning, sharp, dull, and stiff Unable to straighten up or walk without increasing pain 4 Weeks to 12 Weeks Pain, muscle tension, stiffness localized Decrease in quantity/ quality of movement Recurrent 12 Weeks or More Pain quantity and quality varies Theory of central sensitization Treatment Planning for Non-Specific Low Back Pain ACUTE TREATMENT GOALS Decrease pain Decrease inflammation Decrease muscle contracture Maintain pain free range of motion ACUTE TREATMENT TECHNIQUES Lymphatic facilitation Passive Positional Release Strain Counterstain Strain Relaxation massage Energetic bodywork practices (with client consent) 29

30 Treatment Planning for Non-Specific Low Back Pain SUB-ACUTE TREATMENT GOALS Decrease pain Decrease inflammation Decrease muscle adaptation Increase range of motion Maintain core strength SUB-ACUTE TREATMENT TECHNIQUES Soft-tissue manipulation Fascial release Trigger and tender point release Post-Isometric Relaxation Treatment Planning for Non-Specific Low Back Pain CHRONIC TREATMENT GOALS Decrease pain Decrease residual inflammation Restore range of motion Improve function Increase core strength Reduce scar tissue CHRONIC TREATMENT TECHNIQUES Soft-tissue techniques Cyriax Cross Fiber Friction Muscle Energy Technique Active Isolated Stretching Active Muscle Release Contract Relax Technique A key component of all application of technique: DEPTH DIRECTION DURATION 30

31 CLIENT SCENARIO TREATMENT GOALS Reduce muscle contracture Release fascial restrictions Reduce adhesions Improve muscular balance Non-Specific Low Back Pain Defined Part 3: Treating Non- Specific Low Back Pain Red Flags During the Health Intake Process Treatment Goals Video Demonstration 31

32 S-Bends Palmar Compression Reinforced Fingertip Friction Iliolumbar Ligament Cross-Fiber (3 levels) Passive Positional Release QL Passive Position Release (Lumbar Spine) 32