Articles by Kit Laughlin
Kit Laughlin is an authority on the subject of stretching and strengthening, and many areas in between. Kit developed Stretch Therapy over the last 30 years.
He has written two best-selling books about Stretch Therapy, Overcome Neck & Back Pain (for injury rehabilitation, now in its 4th Edition) and Stretching & Flexibility (for performance enhancement, well being, and injury prevention, now in its 2nd edition) and numerous DVDs, videos and many articles.
Kit teaches Stretch Therapy to practitioners of Chiropractic and Osteopathy, Physiotherapy, medicine, Yoga, Pilates and Massage Therapy and to people everywhere who want to rehabilitate or avoid injury, enhance performance or maximise wellbeing, in Australia and around the world.
He was awarded a Master of Letters degree by the Science Faculty of the Australian National University in Canberra (1992) and was granted an Australian Postgraduate Research Award (1993–96) for Ph.D. research, where back pain was the main case study. This research led directly to his first book, Overcome Neck & Back Pain.
Articles for a general audience
Piriformis and its role in sciatica
The effectiveness of treating trigger points in the buttock area is well known. In this short article, I wish to remind you of a biomechanical and muscular problem associated with the hip, and in the process prescribe an effective exercise treatment for the common problem of the piriformis syndrome as identified by Travell and Simons in their excellent Myofascial pain and dysfunction: the trigger point manual (here, volume 2, p. 186 ff.,1992).
Piriformis spasm and sciatica
Piriformis is an external hip rotator, acting with the adductors to facilitate walking and running, stabilising the femur in the sagittal plane so that the prime movers (gluteus maximus, quadriceps and the hamstring group) can propel the body over the legs. Less known about piriformis is that in about a fifth of the general population, one or both branches of the sciatic nerve pass directly through this muscle instead of passing between it and the one inferior to it, gemellus. Accordingly, this muscle can place sufficient pressure on the sciatic nerve to cause the familiar sciatica if it is in spasm. The unfortunate aspect of this for patients with sciatica is that if they demonstrate disc pathology the sciatica they suffer will normally be attributed to it and the possibility of misdiagnosis and ineffective treatment is high. This argument is developed in detail in my book Overcome Neck & Back Pain, 4th edition, Simon & Schuster, 2006, in the Causes of neck and back pain chapter, p. 225 ff.).
The oriental connection
From the oriental medical perspective, both the lung and large intestine meridien pass through piriformis as they run deeply through the body here and the small intestine and kidney meridiens pass above it (following Masunaga). We have found that deep elbow pressure (whether by shiatsu or deep tissue massage techniques) can be effective, if held statically for considerable periods (15-30 seconds). Static pressure is tolerated better by patients with this problem. Occasionally, patients can assist in the penetration of this pressure, by applying a gentle lifting pressure themselves to the leg being treated (for ten seconds or so), then being asked to relax and take a breath in; and you re-apply the shiatsu as they breath out, in a clinical use of the familiar Contract–Relax (C–R) technique. Be careful not to apply too much pressure; the piriformis syndrome when present renders this treatment area extremely sensitive to pressure, and the pain in the buttock can best be described as excruciating.
Necessity of stretching
Pressure alone is rarely effective in my experience. I have used the standard physiotherapy stretches (both solo and partner versions), but felt that they did not get into the area sufficiently deeply. The version presented by Travell and Simons is ineffective (the pressure the patient can apply to the iliac crest is insufficient to isolate the hip against the rotation applied to the knee for length of lever reasons; see vol. 2, p. 211, fig. 10.11). After much experimenting, I devised exercise 16 in my book, which is effective in most cases, and is offered in practitioner-applied and solo versions. If the patient lacks sufficient hip flexor suppleness to get into the starting position, then exercises 6–8 will also be effective. Note that either sciatica or simple hamstring tightness can make even the easiest of the floor versions difficult to use, in which case the table version (where the straight leg is folded at the knee over the edge of the table) can be used. One or a combination of these two exercises has proved effective.
Retest SLRT after stretching
And as I detail in the book, if your patient has been diagnosed with sciatica using the straight leg-lifting test, I suggest that you repeat the test for both legs, noting the point at which either the sciatica or the referred pain is elicited. Perform the partner version of either exercise 9 or 26 as appropriate, and re-test the straight leg-lifting test. In many cases the leg will pass straight though the previous stopping point, often testing 15 or 20 degrees better flexion at the hip without having stretched the hamstrings. If this is the case, suspect piriformis syndrome (this has proved to be the case in over 50 per cent of participants at the workshops I’ve been running around the country this year).
Of course, the piriformis syndrome is not the only cause of sciatica, but you must suspect it if the sciatica has not responded to conventional treatment. Patients with this syndrome will often complain of pain after extended sitting, both in the buttocks and radiating down the affected leg. This problem is commonly associated with an actual leg-length difference (55% of the population have an actual leg-length difference of 5 mm or more; references to five studies provided in chapter eleven of my book), and following lifting accidents. It is often associated with pain in quadratus lumborum.
I hope this brief introduction can be used by you in the clinic, and I shall develop this and other themes in much greater detail in my practitioner workshops.
The role of iliopsoas in neck and back pain & its treatment
Pointers, Journal of the Shiatsu Association of Australia, 1998.
An exploration of the global significance of this muscle group, both posturally and in terms of its role in neck and back pain, dynamically and statically.
Anyone who knows anatomy will be able to tell you that iliopsoas spans the anterior surfaces of the transverse processes and the femur, attaching just below the greater trochanter – but, really, what does this tell us in a functional sense? In respect of neck or back pain, why should iliopsoas be given any more attention that, say, gamellus or any of the other 600-odd muscles around the body?
Before answering that question, let us reflect for a moment on the shape of the spine: as seen from the side, it exhibits the characteristic three curves, the cervical lordosis, as the rearward-facing concavity is known, the thoracic kyphosis, as the rearward-facing convexity of the upper and middle back is known, and the lumbar lordosis, as the rearward-facing lumbar concavity is known. The usual explanation for an excessive lumbar lordosis is that the abdominal muscles are insufficiently strong, which (on this account) lets the brim of the pelvis tilt forward, increasing the lumbar curve. Additionally, any patient with prominent or well-developed gluteus maximus (like a dancer or weight lifter) will often have the shape of their back labelled ‘sway back’ or (more technically) lumbar lordosis (or ‘hyper-lordosis’) by various practitioners because of the illusion of greater than normal curve caused by the shape made by the buttocks joining the lower back. Let us put this myth to rest here: the lumbar lordosis is one of the normal, and necessary, adaptations of the spine, thought by many anatomists to be the primary shock-absorbing mechanism of the body (in respect of longitudinal loads).
Let us return to the role of the abdominal muscles in the shape of the lumbar curve for a moment. It is usually argued that this shape results from weak abdominals, but try this quick test. Stand up, relax, place one hand over your navel, and lift one knee to the chest. Can you feel the abdominal muscles working under your hand? Now try walking around, with the body relaxed. Are these muscles doing any work at all? The answer is no. Of course, it is possible to walk, sit, and stand with the abdominal muscles clenched, but this is far from normal, and in fact is characteristic of a chronically stressed person, and one of the first diagnostic clues when doing hara diagnosis. The point is, even if you do feel tension in these muscles (perhaps your normal way of being in the world) repeat the tests trying to keep those muscles relaxed and you’ll see that you can. The fact is that in much of normal daily life the abdominal muscles do little work apart from providing the small amount of tension required to hold the abdominal organs in their normal position (and some people avoid even this minimal amount of work), and hence cannot play a major role in shaping the lumbar lordosis: no tension means no effect, after all.
Static vs. dynamic
What about dynamic movements, or during lifting events? In dynamic activities (like running or other fast sports) the abdominal muscles are working all the time: they brace the trunk, so other muscles can be brought into play to move either the body itself, or specific limbs, against the inertia of the body, as when you throw or kick a ball, for example. During lifting, the abdominal muscles play a major role: using an automatic, reflex response called the Valsalva manoeuvre (named after the Italian anatomist who first discovered it) we all take in a breath, close both the throat and the anus, and by tightening the abdominal muscles we turn the entire trunk into an ‘inflated splint.’ Some anatomists claim that this reflex decreases the compression experienced by (say) T12 by up to 50%, compared to the theoretical forces that would otherwise be experienced by this vertebra (see Kapandji, for example). So for these reasons we need strong abdominal muscles, but in the majority of daily life they play no significant role in the shaping of the lumbar curves. So which muscles do?
Effect of tight hip flexors
Please refer to the accompanying illustration (p. 39 in second edition, ONBP; p. 63 in the third edition, and p. 69 in the current, fourth edition). As it is presented on the page, the quickest and easiest test of the length of iliopsoas it to lie down face up, with your legs stretched out on the floor. Can you press your lower back to the floor with the back of the legs held onto the floor? If you cannot, suspect tight iliopsoas. The bottom illustration shows why people with tight iliopsoas (and for a moment I am only considering bilateral tightness in these muscles) feel discomfort in the lower back when lying with the legs outstretched: the lower back is literally pulled from the floor by these muscles if they are not loose enough to let the legs rest on the floor. Please turn the page you are reading 90 degrees, so the figures represent a standing person: now you can see the effect iliopsoas has on the shape of the lower back when you look at the leftward-most depiction. Tight iliopsoas is the primary determinant of the shape of the lumbar curve, and people with tight iliopsoas display both an exaggerated lumbar curve and a protruding abdomen. But the effects are not in fact confined to this area of the body, and what I will develop now is one of the reasons we identify iliopsoas as a ‘sufficient’ cause (a term used in philosophy to denote a cause which, by itself, is enough to make something happen) of not only low back pain, but middle back pain and neck pain too. Let me explain.
The spine adapts
If iliopsoas is tight, the entire spine must adapt. The typical way the body achieves this is, as already mentioned, to allow the lower part of the spine to be pulled forward, and some textbooks show this. But if this occurs, the thoracic spine usually increases its curvature too, as the body seeks to keep itself balanced over its centre of gravity, and as this occurs the cervical spine increases its curve in order that the head be held roughly level. We are still talking about each of the iliopsoas pair being tight (bilateral) as a cause. If only one of the iliopsoas pair is tight, these changes still occur, but are made even stronger by the addition of small rotations at all segmental levels. To understand why this occurs, we need to know something of the extraordinary complexity and subtlety of the engineering of the spine. If the pelvis is tilted to one side, as in the case of an actual leg-length difference, one ankle pronating significantly more than the other, or when one half of the pelvis is smaller than the other (‘small hemi-pelvis’), then all lumbar vertebrae will be slightly rotated away from the lower hip side (‘contrarotated’), all the thoracic vertebrae rotated towards the short leg side, and all the neck vertebrae rotated in the same direction as the lumbar spine. This is in fact how lateral flexion is achieved in the normal spine: lateral flexion is achieved in part by momentary wedging of the intervertebral discs, by vertical and lateral movements of the facet joints, and by contrarotation away from the direction of the flexion. Students interested in learning more about this fascinating and complex movement will find a brilliant exposition in Kapandji’s The physiology of the joints, volume three, pp. 53ff.
So, following the movements of the spine, we find that patients demonstrating a tilted pelvis almost always carry the pelvis slightly rotated with respect to the plane of the feet , with the body in the anatomical position. This is something we look for when examining patients: stand to one side and (with the feet in the anatomical position, 300mm or so apart, and inside edges parallel) look at the plane represented by the heels, and look then towards the line of the hips. One hip will be carried further forwards then the other. Normally (although not always) the higher hip will be carried forward. When we test the tightness of iliopsoas with respect to each other, we usually find that iliopsoas of the lower hip’s leg tests tighter. Visualise this area of the body for as moment: if one hip is lower, the spine is laterally curved away from this hip (i.e., it bends back towards the centreline of the body) and the individual vertebrae are rotated towards this hip (contrarotated away from the induced curve) and accordingly the transverse processes similarly rotated. Thus the origin and attachments of iliopsoas are closer on the lower hip side and this is what the body considers ‘normal,’ and one of the reasons iliopsoas tests tighter on this side.
We have a number of innovative exercises to loosen tight iliopsoas, but space does not permit their description. We strongly recommend self-stretches done with appropriate abdominal bracing and strong contractions of the relevant gluteus maximus in the ‘tail-tucking’ action (to counteract the normal tendency of these muscles to hyperextend the spine).
On our workshops we pay close attention to the requirements of i) making sure that the hip whose iliopsoas the patient is trying to stretch is in front of the other hip during the movement (as might be seen from above) to focus the stretch on iliospoas, and ii) an arm is used on the front leg’s knee to brace against, and keep the trunk vertical, and iii) the abdominal brace together with the tail tuck already described. The complexity of these instructions is necessary, as the body will defeat one’s best attempts to stretch these (or any) tight muscles.
In this brief note, I have selected only one of the many causes of neck and back pain, the subject of our six-day intensive workshops. Fuller details of the rationale touched upon can be found in my book, Overcome Neck & Back Pain. Only so much can be covered in words and pictures, of course, and we hope to see more practitioners who deal with these common problems at the workshops in the months to come.
Integrating diagnosis and treatment for massage
How does the practitioner integrate diagnostic processes (such as leg-length testing and assessment of patterns of functional flexibility) into a treatment?
The question of how the practitioner can incorporate diagnostic techniques (assessment of structural and functional considerations deemed relevant to the patient’s problem) into a standard massage treatment is not an easy one to answer. This question give rise to two additional questions: what are the expectations of the patient, and how may they be changed for the patient’s ultimate benefit?
What is the reason for treatment?
The first question may be reworded: for what ostensible reason is the patient coming to see you? The reasons are many and varied, but chief among them are stress management, neck, middle or lower back pain, optimisation of well-being, or some specific musculoskeletal problem. If stress management is the reason, then the practitioner can explain during the treatment that the tension that is being explicitly dealt with in the massage session is in fact the body’s most fundamental reaction to stress. Accordingly, any one of the orthodox approaches to reducing stress is then a natural subject to which the conversations can turn. So, for example, one might talk about relaxation techniques (usually a more gentle term to use than meditation, the use of which can alarm some patients), or the use of stretching exercises to change tension patterns. It is a perfectly reasonable matter, then, to offer to teach the patient a number of such exercise at the conclusion of the session. One could shorten the actual massage part of the session by 10 or 15 minutes explicitly for this purpose. If the use of the exercises by the patient makes a difference to this very common problem, you can be sure the patient will ask you for additional stretching exercises at a future consultation. Over time, one may devote the entire hour to stretching exercises if the patient so wishes.
The Japanese Ambassador
There are patients, however, who only wish their symptoms to be dealt with. For example, when the Japanese ambassador first came to me for treatment, he said that the time he spent in my clinic was the only time in his working week that he could completely escape business and political considerations. Of course, under these sorts of circumstances, one is happy to enter into an explicit treatment of symptoms. As time went by, however, he informed me of a shoulder problem that had been troubling him for many years. So, in line with the model outlined above, I spent some time with him at the end of the treatment (still within the treatment hour) working on his shoulder problem with specific stretching exercises. The fact is that I had worked on his shoulder with massage and shiatsu techniques meant that the stretches were even more effective than they would have been if done on their own. In time the problem resolved.
Neck or back pain
One of the most common reasons for a patient to come to a massage practitioner is for the treatment of the neck or back pain. The practitioner needs to realise that a patient has a specific idea of what it is they want from you, but often lacks the language or concepts with which to articulate their concerns. In the case of neck and back pain, during the taking of the patient history before the massage commences, the practitioner can float the idea of doing a structural and functional analysis some time in the future as a means of making concrete some possible causes of their problem. The initial consultation then proceeds as normal, with a standard massage being performed. During the massage, the practitioner is gaining a much clearer idea of where the patient hold tension, and possibly where the patient lacks strength as well. For example, in the case of neck pain, levator scapulae can explicitly palpated and its tension in relation to surrounding tissues assessed. In the case of back pain, erector spinae (or even quadratus lumborum, If the practitioner is sufficiently skilled) may be palpated, assessed and treated. Comparisons of left/right development of muscles articulating the spine can be made.
Talking about future sessions
At the end of the treatment, keeping these considerations in mind, one may suggest that a future treatment sessions be devoted to a structural and functional analysis, in order to move the treatment away from symptomatic to an understanding of underlying cause. This will entail the possible uncovering of underlying causes such as structural leg-length difference and a comparison of left/right patterns of flexibility. Following this, you might say, certain stretching exercises will be indicated, and offer to spend a future sessions doing practising these.
If the patient is coming to see you for a specific musculoskeletal problem, it is an easy matter for the practitioner to suggest stretching or strengthening exercises as the patient’s homework, and be certain that this course of action is very likely to yield much faster results than simply being treated by massage. This is because dysfunctional patterns of flexibility or dysfunctional motor patterns are the main reason for these kinds of problems. The vast majority of musculoskeletal problems (including, of course, neck and back problems) may be said to be the result of inefficient biomechanics, but so saying does not indicate specific treatment directions. To move beyond a mere description of the problem (even though ‘biomechanical’ does has a nice scientific ring about it!) to a treatment of its cause(s) requires that some analytical process be used. As I have published elsewhere, one such specific and repeatable process is the assessment of physical functions in terms of insufficient flexibility or lack of strength. This relatively simple analysis yields specific treatment recommendations: stretching exercises for areas that testing reveals to be tight in comparison with what is ‘normal’ for that patient and strengthening exercises for areas shown to be weak. This latter assessment will require an understanding of which muscles need to be activated and how strong they need to be in relation to other muscles.
Going beyond a ‘condition’ or ‘problem’
There is a further consideration in recommending specific stretching and strengthening exercises, and that is the notion of empowerment. Far too many practitioners – deliberately or inadvertently – disempower their patients. That is, from the very first consultation, an atmosphere can be created wherein the practitioner and the patient both regard the patient as the more-or-less passive recipient of the treatment being practised. In other words, the practitioner is put forward implicitly as the fount of wisdom, and the patient the vessel. Apart from being patronising, a great deal of recent research in medical anthropology suggests strongly that the likelihood of successful resolution of any problem is lessened considerably if the patient is not actively involved in his or her treatment.
States of mind
So we might say that one could have a process reason for recommending stretching or strengthening exercises (that your analysis has yielded an understanding of specific biomechanical problems in the patient’s system) and a psychological reason. This latter reason is simply (and very importantly) the creation of an optimistic state of mind in the patient, and the passing on of specific tools for the patient to use to resolve his or the problem. This gives the control of the problem largely to the patient – in my view an essential first step up for full, permanent resolution of the problem. Until the patient takes responsibility for his or her own problem, the problem is likely to recur regardless of how effective your treatment is. And please do not be like the practitioner I worked with once who, by the afternoon of the second day of a workshop could see how effective the techniques are, and, accordingly, was terrified about his patients getting better and no longer needing to come to see him! Embrace success, and be assured that if you can actually help someone’s problems, they will tell everyone they know, and there is no doubt at all that word-of-mouth advertising is the best.
Integration of treatment elements
If the practitioner embraces an analytic protocol as, for example, outlined in the book Overcome neck & back pain, the structural and functional analysis will take about 30 minutes in total. Assuming a treatment hour, the remainder of the time can be used in the teaching what the analysis reveals to be the most likely significant two or three exercises. At a future consultation, you will be able to concentrate on whichever muscles the analysis has revealed to be excessively tight, in addition to the massage process that you usually use. At the conclusion of the massage, spend 10 minutes reviewing the previously-taught exercises with the patient. Experience has shown that no matter how well these exercises are taught the first time, reviewing them a week or a couple of weeks later will reveal practise errors; we are all human, after all, and patients (and practitioners) alter the form of an exercise to make it more comfortable, and often avoid the target area as a result.
Progressing the intensity of the exercises
I have found that once the pain of the initial problem has receded, it is usually necessary to teach some strengthening exercises in order that the patient returned to full normal (or, desirable) function. We might say that in order for rehabilitation to be considered complete, the patient must move beyond the pre-injury state of fitness that led to the initial problem. In respect of neck pain, the anterior neck muscles usually need strengthening. Any tendency to carry the head forward of the ideal position will also need to be corrected, and this usually requires the strengthening of muscles in the lower abdominal area. In addition, it will be necessary to check the flexibility of the hip flexors, iliopsoas and rectus femoris, in particular. This is because the research has shown that an anterior pelvic tilt can be the main cause of the forward-head posture.
If lower back pain is the initial consultation problem, it is usually necessary to teach effective strengthening exercises for particular muscle groups once the pain has settled down. Without wanting to preempt your testing procedures, experience has shown that the lower abdominal muscles, transversus abdominis, and the relationship between the strengths of the internal and external obliques usually needs attention. Recent work I have done with Paul Chek confirms the claim that strengthening exercises are most efficiently done using an exercise ball. All of the abdominal strength the exercises in my book Overcome neck & back pain can be done this way. I believe the usefulness of the exercise ball lies in the elicitation of some primitive reflex arcs, which in turn reactivate the righting and tilting reflexes. The reason this is important is that life, and inefficient exercise patterns, tends to worsen existing imbalances and frequently strengthens the upper abdominals preferentially. As these attach to the ribs, increasing their strength without attention to how the body uses the other abdominal muscles can actually worsen one’s posture. Exercising over the Swiss ball, an extremely unstable environment (especially for those people who have never done any strengthening exercises before) wakes up the fundamental reflexes and allows the patient to re-establish desirable patterns. I am happy to report here that results come extremely quickly, especially with patients to have no experience with exercise.
Speaking generally, massage practitioners are uniquely poised to take advantage of recent breakthroughs in rehabilitation medicine techniques. Because of the physical basis of the massage practice, many practitioners already have a deep intuitive understanding of how the parts of the body work together. To make massage practitioners the preeminent rehabilitation practitioners in the new millennium, all that is needed in my view is to acquire an effective understanding of efficient stretching and strengthening exercise techniques in addition to the specific massage modality one uses.
It is no accident that massage practitioners are very often the first recourse in people’s daily life problems. This is because massage therapy has a very low incidence of unwanted side effects and because the treatment is with friendly and supportive. The atmosphere created in the treatment facilitates a deep exploration of the causes of any particular problem – psychological and emotional as well as physical. It is also no accident that massage practitioners form the bulk of those who attend my workshops – and others who teach similar techniques – and are among the most open minded of practitioners, too.
As an aside, it is for this reason that I’m somewhat concerned to see the trend in massage therapy going towards more and more formal qualifications. This is not to say that there are not specific areas of knowledge that are essential to good, and safe, practice. My concern is that as the focus in massage goes towards the academic style of learning, the foundation of good practice – exquisitely sensitive sense of touch and an understanding of how to change the state of the tissue underneath one’s hands – may be lost. I urge practitioners to maintain the tactile foundation of their practice and augment it with knowledge that can be explicitly and efficiently applied in your practice, and the experiential learning of stretching and strengthening exercises is one of the most grounding and effective ways of achieving this.
Neck and back pain: are conventional treatments effective?
Briefing prepared for A Current Affair, 1997
The background information that led to three appearances on ACA, and which started all our workshops!
We have been presenting workshops around the country since the exposure of the Overcome Neck & Back Pain approach in January. In this short note, I wish to present a precis of the main points of the book Overcome Neck & Back Pain, and the confirming evidence of approximately 1,500 workshop attendees since the approach was aired on A Current Affair.
Structure and function
Put simply, structure and use determine function. By this I mean that the way the various bits of the body work are governed first by their structure and second by how an individual uses his or her body. Examples: if you spend your day hunched over a computer, the levator scapulae and sub-occipital muscles are likely to hold excess tension, because they are both doing work and are holding a relatively fixed position.
Adding stress to the equation
When you add stressors to that mix (like being under pressure to hit a deadline by close of business) these muscles reach their work limit before the rest of the body and tension and pain results. Over time, the way the body uses itself changes. As another example, consider the recreational jogger: the activity requires many repetitions of small range of movement actions. Patterns of tightness (which are simply reflections of those use patterns) result. Check structure first. If one’s structure is not symmetrical, then the forces acting on the body (mainly gravity and the way it is resolved in various activities) will not be distributed as widely in the body as nature intended.
If the structure is not symmetrical, one half of key paired muscles does more work. Doing more work makes it stronger than its pair, but tighter too. We have found an inverse relationship between strength and flexibility; that is, if one of a pair of muscles is stronger then it will be tighter too. This means that it reaches its work limit before the other. The main asymmetry of interest is leg-length difference. If you include the figures from 5-9mm in addition to the 10mm or more difference figures, then around 55% of the population have a leg-length difference of 5mm or more. This can be corrected by an insert in the heel of the shoe of the short leg (usually around half the difference; we don’t want to make the body’s adaptations a problem too).
The reason leg length difference is significant is because it tips the pelvis to the side of the short leg, and the three normal curves of the spine are subtly reproduced in the plane between the shoulders, resulting is an ‘S’ shaped curve, as seen from behind. Generally this then causes additional development of the muscles on the outside of these curves (see illustration on p. 242 of the current, fourth edition). Having one leg shorter than the other can contribute to neck pain as well: when we consider the shape of the spine from behind, we may be able to see that one shoulder is carried higher than the other. This may be due to right- or left-handedness (dominant arm’s shoulder and neck muscles better developed and hence tighter) or it may be because that shoulder is carried on the outside of the induced thoracic spine curve. These causes can add together.
With respect to back pain, such asymmetry can have different outcomes: either simple muscle tension on the short-leg side, through additional development and commensurate tightness, or through compression on the long-leg side. In severe cases this can result in sciatica (pains down the back of the leg).
Comparing key functions
Now we check function. Even if no leg-length difference is found, a comparison of key functions of people suffering neck or back pain will usually reveal marked asymmetry. The key functions are: right/left lateral flexion, right/left rotation, right/left hip flexor tightness, and general lumbar muscle tightness. Should hip flexor tightness be revealed, check quadriceps tightness too. This is because some part of the quadriceps cross the front of the hip joint and mimic hip flexor action in terms of tilting the pelvis forwards; this aspect of our body also explains why the conventional sit-up can hurt the lower back.
Reducing tension in the affected muscles gives speedy relief. There are only three ways of reducing tension in muscles: using one of the psychotropic drug family members, efficient stretching exercises, and developing the capacity to relax. Valium, Librium and other similar drugs act as CNS depressants and muscle relaxants. In my view, they should be reserved for emergency use. The C–R approach to stretching is the most effective in this regard. C–R means taking the limb into the stretch position and getting used to that stretch for a while, gently contracting back in the opposite direction for a few seconds, and then on a breath out, restretching the affected part. It will always go further; and these improvements accumulate. Often a single iteration of the right stretch will give relief. Done over time they change the way the body holds tension. Conventional stretching often merely hurts. Developing relaxation habits helps the body repair itself. Most people these days hold excessive tension in different parts of the body, and we know that this is caused mainly by stress. Learning to relax helps you to sleep more deeply, and helps you be more aware of how stress creates your individual tension pattern in your waking hours.
Getting back to work
Many studies have shown that the prognosis for a full return to work after time off for a broad range of back problems is poor, if the patient has not returned to work within twelve weeks of the onset of the problem. What I wish to address in this brief note are some of the possible reasons for this statistic, and make some suggestions for strategies we have found effective in the pursuit of the goal of full return to work.
Leaving aside for a moment certain aspects of the relation between injury and compensation, it should come as little surprise that return to work is less likely after a protracted period of absence: the simplest analysis suggests that the patient will have adjusted his or her lifestyle to use the time that is usually spent at work to pursue a variety of endeavours, if enough time passes. Researchers have identified a cluster of entailments that follow the identification or diagnosis of a condition by a health care professional that are called the Rumpelstiltskin effect.
The term refers to processes that occur as a result of the naming of a range of symptoms as a recognised illness or syndrome, and a number of changes in perspective immediately result: the patient is aware that the problems he or she suffer are not unique; that there may be a cure; that obligation for daily life responsibilities is lifted or reduced; that absence from work is licensed; and, in some cases, compensation or rehabilitation is available. The adoption of this cluster of effects flowing from the diagnosis has been termed the ‘sick role,’ and it is a role from which some patients never recover. As practitioners, it is our task among others to minimise the number of patients who adopt the sick role and the most effective way is to help the patient help themselves and to teach them effective ways to restore normal, or better than normal, function to the body.
Assuming the patient has a strong desire to return to full duties, let us consider some of the barriers the patient perceives are preventing that goal. In order of significance, they are pain; dysfunction; and fear of recurrence of the original injury. Further assuming that the patient is not demonstrating neurological deficits, we have found that the careful use of the Contract–Relax (C–R) approach to stretching to increase the range of movements in the affected muscles to be most effective in relieving pain (Laughlin, 1995, p. 15). The most commonly implicated muscle groups in low back pain are (in order of frequency of involvement, as found on the Overcome neck & back pain workshops, n=1,350) quadratus lumborum, erector spinae, occasionally latissimus dorsi if the pain is felt over the sacro-iliac joint, and piriformis, if hip pain or sciatica is present.
The latter muscle group can be highly significant, as cadaver studies have shown that the peroneal branch of the sciatic nerve pierces piriformis in about a fifth of the population, and simple spasm in this muscle can produce sufficient clamping force to the nerve to cause what appears to be full-blown sciatica (Travel & Simons, 1992, v. ii, p. 186 ff.). When we consider that two-thirds of the non-back-pain suffering population exhibit disc or joint pathology of sufficient severity that the identified pathology would be judged to be the cause of the pain – had they had any – one can see the necessity of ruling out piriformis syndrome (Jensen et al.). Additionally, the hip flexors need to be assessed, for approximately 30% of back and neck pain patients demonstrate tightness in this area, and this will contribute to postural dysfunction (see Laughlin, 1995).
We have found that many long-term back pain sufferers have markedly reduced flexibility in many other places in the body besides the area in which the pain is experienced. This is what is meant by dysfunction, and may not be related in any causal way to the medical problem. We have found, for example, that hip flexion and hamstring tightness is a consequence of back pain rather than a predisposing factor (in fact tight hamstrings helps flatten the lumbar curve, an exaggerated lordosis being commonly cited as a cause of low back pain). Improving range of movement at the hips (using a simple supported exercise on a chair; see exercises 1 and 2 in Overcome Neck & Back Pain) gives the patient immediate improvement in forward bending. I feel that this sort of dysfunction is nothing more than the normal protective mechanisms of the body – in this case the muscles of the trunk and of the hips tightening (the familiar ‘splinting’) to prevent further injury – but no longer serving useful purpose. We have found that this sort of dysfunction is highly correlated with the pain of the problem, and that improving the range of movement of both the affected and surrounding areas is effective.
The last point I wish to address is the patient’s fear of recurrence of the original injury. It is here that the conventional notions of rehabilitation are insufficient: returning the patient to a pre-injury state of fitness is clearly no guarantee of a further episode. Depending on the patient’s lifestyle, and upon successful completion of the basic exercises covered in chapter one of my book, the patient may proceed to the more difficult stretching exercises. Practising these movements makes the body demonstrably more supple, and the awareness of these changes is a valuable part of the progress to full return to work. We find that a month to six weeks work on the basic exercises reduces the pain experience significantly, and the majority of patients can then proceed the exercises of chapter two, Rehabilitation and prevention.
Going beyond ‘recovery’
Those patients who wish to go further are advised to consult the later chapters, which includes a range of strengthening exercises. Most people will only need the first two, which can be done at home, and which strengthen the trunk and intrinsic lumbar muscles. The more advanced stretching exercises and the basic strengthening exercises are all most people need. The practise of these movements instills confidence in the patient, and the increased awareness of placement of the body, the development of the feeling of some strength in the middle of the body, and being made aware of safe lifting techniques all contribute to the patient’s return to work.
Jensen, M. C., Brant-Zawadski, M. N., Obuchowski, N., Modic, M.T., Malkasian, D., and Ross, J. S., 1994. Magnetic resonance imaging of the lumbar spine in people without back pain. New England Journal of Medicine, July 14. 331, No. 2: 69-73
Laughlin, K., 1995. Overcome Neck & Back Pain. Simon & Schuster, rewritten and revised 4th edition, 2006
Travell J. G., & Simons , D. G., 1992. Myofascial pain and dysfunction: the trigger point manual, volume 2, Williams & Wilkins, New York
Articles for a technical audience
Supervenience, massage and stretching
Prepared for the Australian Association of Massage Therapists, April 2004
Massage is often the first recourse for people with sore and aching muscles, and massage has been practised with these problems in mind for thousands of years. Few working practitioners confine themselves to these problems today, however. The range of problems considered tractable to the various forms of massage is vast; examples include general and specific tension associated with stress, neck and back problems, postural problems, sporting injuries, digestive problems, headaches, and the pursuit of enhanced well being.
All forms of massage use manual techniques applied to the surface of the body. The general goal is reduction of tension held in the muscles and fascia (or a redistribution of tension, according to principles that vary between different forms of massage), and that, among other effects, blood flow will be enhanced and the state of mind improved.
The deep belief of any bodywork technique is that improvement in health will follow this kind of physical intervention. In this note, I wish to argue for an addition to your present techniques – specific stretching exercises – and will support this with reference to a branch of philosophy, called supervenience theory.
The term ‘supervenience’ describes the relationship between ‘global properties’ of all complex systems and the ‘subvening’ (or smaller, comprising) parts. By ‘global’ we mean large-scale properties or functions. For example, talking about a patient, the term could mean the capacity to place a hand on the back between the shoulder blades. By ‘subvening,’ we mean the comprising systems, or their parts. In this example, this could include the skeletal system, the circulatory system, the nervous system and so on. In oriental systems the skeletal system would be part of the explanation, but so too would the meridian systems, and that mysterious substance ch’i.
The only relation between levels in complex systems can be stated simply: there can be no change at any level without a change at an underlying level. Specifically, bringing about change to a supervening property (or function) entails a change to either the properties of one or more of the subvening parts, or a change to the relationship between these parts. As far as anyone has observed, the supervenient relation is always found when complex systems are observed. Until recently, however, this relation was thought to be too general to be any practical use.
For all practitioners, supervenience is the fundamental relation that underlies the interventions that occur in clinics every day. Within these relations, a smaller set of relations is found – cause and effect, or symptom and cause.
Very few problems treated by massage are single cause problems, such as when a patient presents to hospital with a broken bone, for example. The vast majority of general health problems are multi-causal; accordingly, a real problem for the practitioner is ‘what is the relationship between the causes identified in the system?’ Do they interact (assuming two causes) in such a way that they add to each other making the condition worse, or do they perhaps balance each other with no net effect, or does the presence of one cause render the other possible cause inactive?
Back pain can help illustrate the problem. The anatomically-short leg is an accepted cause of low back pain (through the asymmetrical stresses imposed on the spine through pelvic obliquity; see Laughlin, 1998, p 157ff. for a detailed analysis) but having one leg shorter than the other may be an aggregating (additive) or a countervailing (making neutral) cause of middle back pain, and similarly for neck pain – depending on (for example) which is the patient’s dominant arm. The point is that a shorter leg may cause one problem (back pain), yet may help neck pain.
Consider a patient with a shorter right leg and whose spine has adapted in a subtle ‘S’ shape in the plane between the shoulders, as would be seen from behind (see Travell & Simons, 1992, p. 54, or Laughlin 1998, p. 172). Other things being equal, this patient will carry the left shoulder on the outside of a right-facing thoracic concavity, and the muscles of the thoracic spine are usually more developed on the outside of this curve, as a necessary adaptation to the effects of gravity – more work is done by these muscles to hold the body straight. This can explain why a right-handed patient can have more tension on the left thoracic spine.
If this patient is left-handed, the shorter right leg may be an aggregating cause for middle back pain (tension from two causes being experienced at the same point), but if the patient is right-handed, the same phenomenon may cancel the first cause – and the patient who otherwise might be expected to have neck pain (through right-arm dominance) is pain free!
Too often, however, obvious cause(s) for a patient’s problem cannot be found. Does this reduce you to treating symptoms – in fact, to giving the sort of treatment that other branches of medicine are sometimes criticised for? Not at all. The most useful aspect flowing from the supervenient relation is that if we cannot locate cause(s) for which we have treatment, we do not need to know the precise cause or causes of the problem to know that beneficial intervention is still possible.
We choose a function or functions which we know are out of the normal range (or out of balance, if doing left/right comparisons within an individual) and prescribe techniques that we know are likely to improve the function, being confident that if sufficient change is provoked in the patient then other supervenient properties – like pain or dysfunction – will also be altered. This is where stretching exercises come into their own.
Suppose that you have a patient with low back pain on one side, but there is no evidence of a leg-length difference or significant asymmetry in lifestyle. We know from the symmetry of the skeleton in the coronal plane that certain functions deriving from this plane should also be symmetrical. In every case of back pain I have come across in more than twenty years of practice, this has not been the case – and this observation is independent of whether the patient is flexible or inflexible compared to the normal population.
Accordingly, we test certain functions, using specific parts of exercises: left/right rotation, left/right lateral flexion, left/right hip flexion, and left/right hip extension. In all cases treated so far, these four simple tests reveal characteristic asymmetrical patterns.
We treat the tighter of the patterns with specific exercises and we find that the problem resolves itself as the patient acquires functional symmetry. The practitioner does not need to know which structures are involved, or why. Instead, the power of the supervenient relation is exemplified. The practitioner begins by identifying deficient function, which will be a suitable supervenient property of the system, chosen with respect to general knowledge of the system, and will prescribe a range of techniques known to improve the particular function. If treatment is successful, improvement in function leads to improvement of the original condition – here, decrease in pain, another supervenient property of the system.
In conclusion, appropriate stretches should be used with your clients, and taught to them at the conclusion of the treatment. You will need to know which ones, and how to teach them properly! Because your treatments will be longer-lasting and more effective if you do, your reputation will be enhanced. Your client base will increase, because word-of-mouth advertising is still by far the best, and certainly it’s the cheapest! And your practise will improve because you will not be seeing the same clients week after week with little or no change: when you show them the right stretching exercise, they start to take responsibility for their own problems and, as we all know, until that happens no real change is possible.
Laughlin, K., 1995. Overcome neck & back pain. Simon & Schuster, 3rd edition, revised, 1998.
Travell, J.G. and Simons, D.G., Volume1, 1983; Volume II, 1992. Myofascial pain and Dysfunction: The Trigger Point Manual. Williams & Wilkins, Baltimore.
Kit is the author of Overcome Neck & Back Pain, and the presenter of the national workshops of the same name, as well as the originator of the Posture & Flexibility system. His PhD (ANU) research examined the relationship between information generated in different disciplinary frameworks.
Low back pain: Review and Prescription
Writers, philosophers and surgeons share a common dilemma: in order to be able to begin, they must decide where to put the knife in. The foci of interest must be decided, and the ontology and epistemology that will be brought to bear on the subject defined. In this essay, the reader will be informed of the derivation of the reference sources, and what has been left out of the study and why will be described. The essay will briefly review current medical anthropology, and briefly review the philosophical and epistemological inheritance of the particular ethno-medicine under study.
The focus of this paper is a common illness, low back pain, which will be referred to from now on simply as “back pain”. Back pain has been described as, “A wilderness across whose inhospitable terrain orthopaedic surgeons, neurosurgeons, physiotherapists and, above all, general practitioners are doomed to travel .” The medicine under study is biomedicine, called “allopathic,” “cosmopolitan,” “Western” and “modern,” among others; in any case the dominant form of the many forms of medicine available in Australia today.
This paper will attempt an anthropological analysis of the area of study. That is, anthropological as defined by Young, “A viewpoint in which one’s own concepts and ideas are simultaneously privileged and part of a cultural system, and thus also subject to analysis [90:260].” Young also identifies a group of anthropologists whom he identifies with the explanatory model of illness approach, and whose work we will draw upon. Most important among these anthropologists are Good and Good , and Kleinman [30, 30a, 42, 43]. Their areas of interest are primarily the clinical encounter and medical efficacy, and their focus is the individual. Other anthropologists important to this paper are Taussig  and Moerman [52, 53], the former because of his emphasis on the effects of social structure on medicine and the latter because of his emphasis on the mind’s effect on bodily processes; or as Young so neatly puts it, “The effectiveness of healing on curing [90:266].
Before reviewing the literature on back pain, I will outline a brief history of biomedicine, in an attempt to trace the antecedents that have led to its current development and attitudes. A following section will look at the reference articles and relate them to the work of the anthropologists mentioned above. Hahn and Kleinman have noted that medical anthropology has assisted biomedicine in its search for efficacy in some ways by shedding light on the whys and wherefores of practice [30a], and in similar fashion, the final section includes some suggestions for how general practitioners might improve the clinical efficacy in the treatment of back pain. The essay will conclude with a few suggestions for a preventative medical position.
Reference sources – see the appendix for important notes in regard to selection criteria and methodology for the articles, books and anthropology sources.
A brief history of biomedicine
As has been noted by many writers, Western science (and one of its subsets, biomedicine) can trace its roots back to Plato and Aristotle. In modern times, most historians agree that the writing of Descartes, Newton and Galileo have had the most profound and lasting effect on today’s science.
Descartes is remembered for his “method of doubt,” in which he made it clear that mathematical reasoning would be the basis for his proposed new system of knowledge, and his assertion, “Je pense, donc je suis,” with its proposition that the world is made up of two distinct and incompatible substances. He postulated that the mind or consciousness is unextended and indivisible, and that matter is extended and divisible. His conclusion was that our physical bodies including our brains, being part of the extended divisible world, are not part of our essence as thinking beings. While philosophers argue to this day over the logic used to arrive at this conclusion, this absolute division of the mind and the body, known as “Cartesian Dualism,” has exerted a lasting effect on philosophy and general thought to this day.
Newton’s work on planetary motion and gravity and his assertion that the universe is a vast machine of matter and motion obeying mathematical laws supported the Cartesian worldview. His explanation of gravity in particular, helped the scientific world to focus its attention on the “how” of processes, and not the “why”: that the measurement and quantification of phenomena was to be the paradigm for scientific analysis, and this “positivism’’ is still the “public face” of science.
Galileo’s motion experiments combined reason and experimentation and lifted science to a new level of abstraction. In particular, Galileo postulated ideal conditions such as frictionless planes and zero air resistance for his experiments and in combining rationalism and empiricisms, established the distinction of fact and value. This allowed the scientist to step outside Nature and to reify it: he became the detached observer.
Such detached observers founded various branches of science and medicine and important discoveries were made: blood circulation (Harvey), physiological and cellular processes (Bernard and Virchow), and microorganisms (Pasteur); thus cellular biology and the germ theory of disease were established as the bases of medical science [13:122-25]. Eisenberg echoes this, “Biology has been institutionalised as the fundamental science of biomedicine [17:10].” Engel identifies the Church as a further important influence on the biomedical model, in its permitting dissection. Coupled with the science of the day with its emphasis on “isolable causal chains or units,’’ the study of anatomy via dissection reinforced the premise of the functioning of the whole being able to be understood by an analysis of its parts [18:42].”
Although historically the criteria for the identification of disease have always been behavioural, psychological and social in nature [18:41], it is clear that through the rigorous deployment of the scientific method, these causal agents have been pushed further into the background, or eliminated altogether. To quote Engel:
Biomedicine assumes that disease will be fully accounted for by deviations from measurable biological norms, and as such, there is no room within its philosophical framework for consideration of behavioural, social or psychological dimensions of illness. Implicit in this view is that behavioural aberrations must also be explained in the same terms [18:39].
The successes of the scientific method as it has been applied in Western medicine are numerous, but not without cost. We are left with, “the notion of the body as a machine, of diseases as the consequence of breakdown of the machine, and of the doctor’s task as repair of the machine [Capra quoting Engel, 1977].” Galileo’s legacy of the detached observer has led to what Capra has described as the main problem of the biomedical approach:
…the confusion between disease process and disease origin: instead of asking why a disease occurs (and how it might be prevented) researches focus on the biological mechanisms involved, and how they may be altered [13:150].
In the Western medical model, the body is regarded fundamentally as a machine or a collection of biological processes. Illness may be a breakdown of a part of the machine or something may invade the machine’s external barriers and disrupt the internal processes; in this case, diagnosis involves identifying the invading organism or agent. A specific condition is diagnosed by identifying specific symptoms and a particular instance of a disease is found and labelled. This process uses the cause and effect model, or more precisely, effect and cause. The process of curing uses some means of eliminating or repairing the cause of the condition. Chemical or surgical means are usually applied. It must be remembered however that a model is nothing more than a belief system used to explain natural phenomena, and that scientific models are primarily designed to promote scientific investigation. The tendency to mistake the model for reality can have unfortunate consequences. Two important consequences are described by Engel and Eisenberg, “In the West, the scientific model has become the West’s culturally specific perspective on disease and has acquired the status of dogma [18:40].” and, “The models physicians use have decisive effects on medical behaviour- including what kind of data they collect and what kind of data will be excluded from consideration [17:18].”
There is one further legacy of the reductionist approach: a hierarchy of importance of the various branches of medicine, the effect of which extends across social and financial boundaries. Surgery and internal medicine head the list, with the talking cures (psychiatry) rating much lower. Even organs occupy particular places in the hierarchy, with the heart and brain (and those who work with them) having higher status than the lowly kidney or digestive tract. Both financial remuneration and access to high technology follows these divisions [30:315]. Back pain does not rate a mention on this scale.
Clearly, the prevailing attitude to health care is curative rather than preventative. Western medicine, arising from and bound to the reductionist scientific approach, has its own vocabulary and is usually experienced through and interpreted by another person, deemed by society to be qualified to do so. Medicine and its associated apparatus seems impenetrable and inaccessible to the average person, and many doctors seem to try to preserve this attitude. The common habit of abrogating the responsibility of one’s own health to a doctor, or at least externalising the relationship between one’s self and one’s state of health, can be traced to the mechanisation of the body, the separation of the body and the mind, and the perceived need to seek the services of one who is qualified to mediate between them.
The back pain articles
A review of the 48 articles and the 13 books containing references to back pain allows the making of a number of observations about the changing nature and current state of biomedicine’s attitudes to back pain. These may be summarised:
(i) that back pain is more or less inevitable
(ii) that back pain is one of the most common reasons patients seek a doctor’s services
(iii) that back pain costs the community dearly
(iv) that biomedicine regards vertebral pathology as the cause of the great majority of back pain episodes
(v) that despite (iv) above, biomedicine acknowledges that over 50% of back pain episodes spontaneously remit within one week
(vi) that treatment is reactive, not preventative
(vii) that the biomedical model is expanding to include modalities of treatment once labelled “fringe practices” only a few years ago
Each of these points will be addressed in turn.
The seeming inevitability of the illness has much to do with both the mechanistic and reductionist model of the spine, and the way its individual parts are related to it and how this model is then related to the person as a whole. Anatomists and physiologists claim that the lumbar lordosis (posterior concavity of the lower spine) is a major weakness of the body, due in part to the shearing forces present at the lumbral-sacral interface (L5-S1). Kapandji suggests that during the transition from quadrupedal to bipedal movement, the spine which originally was curved anteriorly, became straight and then curved further to is present state. The normal lumbar lordosis results because the pelvis has not tilted far enough posteriorly. The same changes in curvature from anterior to posterior are observed during the first ten years of life [39:16]. Henderson states that the lumbar spine of most quadrupedal vertebrates is a smooth anterior curve; those animas with lordotic curves (many dogs and horses) also suffer spinal problems. Thus, man is predisposed to spinal pathology [32:1156]. Bedbrook notes that many aboriginal races have a very low incidence of back pain and attributes this to their not assuming the erect position any more than necessary; the squatting position in fact reverses the lordotic curve and stretches the posterior lumbar muscles . Taylor states that disc prolapse is, “decidedly rare in primitive people,” ascribing this to the use of the squatting posture. Littler says that, with the adoption of upright posture, the “axial” skeleton is subject to conservable compression forces for which it was not designed [50:59]. This sort of anatomical determinism illustrates Eisenberg’s notions of the influences of medical models on data collection quite well [17:18].
The above arguments seem somewhat teleological – the lumbar curve can also be seen as a superb adaptation mechanism: without is three curves (cervical, thoracic and lumbar), the spine would have almost no longitudinal shock absorbing capacity and each step would jar the skull [39:87]. Film analysis has shown that while walking or running, the head hardly moves vertically at all, and most pelvic movement is absorbed by the curves of the spine tightening and releasing. The argument of maladaptive evolutionary change does not explain those people who never suffer back pain (by calculation from the figures below, around 20% of the population). A brief description of the physiological support systems of the spine will be made in a later section.
The ubiquity of the problem is quite staggering. Estimates vary, but at least 5% of all patient visits to the doctor are due to back pain ; and it affects between 60% and 85% of the population [22, 28, 31]. In different studies, researchers reported that 21% of patients had experienced back pain in the 14 days preceding the study , 22% of males and 30% of females had back pain at time of study , and 30-40% of the group in another study . More chronic back pain is suffered by women than men . In the sports world, the picture is far from clear: Rovere writes that back pain is relatively uncommon in competitive athletes ; five years earlier in the same sports medicine journal, Stanitski writes that back pain is one of the most common complaints of athletes .
The cost to the community is immense, even if one considers only the figures that relate to financial costs. For example, more working hours are lost annually from industry through back pain than to industrial action , back pain accounts for half the workers’ compensation payments in the U.S and Australia , is the single greatest cause of lost work time  in both countries, and costs $18 billion annually or 3% of the U.S. national budget . (This “budget” was not defined). The social cost cannot be calculated – back pain is the most frequent cause of inactivity in people under 45 years of age and the 10% of patients who suffer chronic back pain cost 75% of the compensation payments. However, Quintner notes that only 8% of persons with a compensable back injury used any rehabilitation agency.
Vertebral pathology is accepted as the causal agent in the great majority of back pain episodes. Ganora states, “…There is little doubt that most cases are due to derangement of the intervertebral joint in association with ‘degeneration’ of the disc and arthrosis of the facet joints.” However, in his following sentence, Ganora says, “Exactly which structure within this motion segment are the actual sources of pain remains conjectural .” “Treatment over the years has been a series of ‘empirical enthusiasms’ .” A research paper in 1934 identifying lumbar disc protrusion or “lesion” as the cause of low back pain led to the period during the 40’s and50’s being described as, “the dynasty of the disc” and many “exploratory” laminectomies were performed with “indifferent results” . Taylor describes the “mammoth surgical exercise” of the same period as inevitable, because the solution appeared simple – removal of the disc would cure the problem . Conrad reminds us about the controversy surrounding tonsils and tonsillectomies: that the well-functioning of organs is a problematic concept, and that changes to organs or systems may be due to environmental adaptations [14:104]. No studies placed any emphasis on lifestyle as an environmental mechanism that causes adaptations – some of which can be good and some not.
Murtagh notes that the most common cause is “soft tissue injury”, but that such patients do not come to the doctor’s surgery; and of those that do, vertebral dysfunction accounts for 67% of their problems . Disc degeneration is the most common cause according to Littler, although vertebral collapse or displacement may also present . In another article, Murtagh states that there is considerable debate as to the causes, opinions being divided between disc prolapse and “overriding” (subluxation) of the pain-sensitive apophyseal joints; he described back pain as the “Achilles heel” of the medical profession and that, “we do not enjoy a good reputation for its management .” Patkin ponders the cause: is it discs, ligaments, or muscles ? The only doctor who speculated on the role of muscles and muscle spasm in back pain wrote that he had been impressed with the amount of improvement in low back pain using treatment aimed at producing muscle relaxation.
In comparison to general practise, most instances of back pain in sports are attributed to strains or partial ruptures to the extensor muscles, mechanical distortions to the intervertebral joints, or chronic over-use .
In a number of biomechanical studies, professor Hirsh showed that there were no striking differences in mechanical response between normal and degenerative discs: therefore, morphological changes to the disc may well be asymptomatic and not necessarily a cause of pain . Littler notes that most patients over 35 years of age show discographic evidence of disc degeneration . Other surveys suggest that in over 80% of cases, no definite diagnosis can be reached . For the last word on causes, Professor Taylor wrote:
Often, even after the most careful clinical and radiological assessments, one has to be content with a decision that the patient has a mechanical disorder of the lumbar spine, the cardinal features of which are pain worsened by movement and relieved by rest. This non-specific, rather inelegant diagnosis satisfies neither the physician nor the patient…The medical profession has a penchant for inventing disease processes on the flimsiest of evidence…Catch phrases such as low back strain, lumbago, lumbo-sacral strain, myofascial syndromes and so on have appeared in the most prestigious journals and text books as medical entities and for some inexplicable reason remain there, unsupported by a scintilla of scientific evidence and notably, clear documentation of the hypothesised pathology .
The figures on spontaneous remission of the problem are extremely interesting and can be interpreted in different ways. In one Australian five year study, 82% of patients suffering a back pain episode returned to work in less than five days [10, 61], although 48% of these same patients suffered up to three reoccurrences of back pain during the study period . In the same study group, only 2% had undergone surgery. The vast majority of back pain is “self limiting”, regardless of underlying causes . Littler points out that 44% of patients consulting a GP recover within one week, 86% within a month, and only 8% are still in pain after two months . Littler goes further, “It is fortunate that so many of them tend to recover spontaneously as we have little specific therapy to offer .” Brooks, reviewing wide-scale studies of various treatments, states that a patient’s return to work did not seem to be related to treatment and notes that the response to a “no treatment” regimen would have been interesting to observe .
(vi) Biomedicine reacts to problems rather than prescribes how to avoid them. In the articles surveyed, no preventative medical position could be found. The doctors whose speciality is rehabilitation come closest, but their efforts are aimed at restoring a “pre-back pain-episode” level of function only and therefore cannot be construed as preventative. This attitude of reaction is fundamental to biomedicine: the notion of repair of the machine. Capra offers a moderating observation on this point however, “Many people obstinately adhere to the biomedical model because they are afraid to have their lifestyles examined and to be confronted with their unhealthy behaviour [13:165].”
Lifting is the most common cause of injury at 61%, with failing (15%) and bending (11%) much less common . For this reason, rehabilitation tends to focus on teaching people how to lift correctly [22, 60], and gentle stretching and strengthening exercises [22, 56, 57]. Somewhat problematic is the illustration of correct lifting technique in Australian Safety News: the arms of the wooden model are significantly longer than its legs. This device, described as “scientifically designed”, is advertised by the National Safety Council as an aid to teaching correct lifting techniques. One can only speculate as to its efficacy.
As might be expected, the sports medicine journals go further in identifying muscle weakness and stiffness as causal agents in back pain and offer a variety of methods to overcome such problems. Based on the preceding material and the author’s clinical experience, the following comments are offered. Some of the exercise programs suggested were comprehensive, but seemed to neglect the area of the body most vulnerable to injury, the trunk [19, 20, 21, 46]. The trunk muscles support the lumbar spine, and it should be noted that increasing the strength of the arm and leg muscles in relation to the trunk muscles can lead to an increased imbalance, which may predispose towards injury. The recommendation against the use of an object to elevate the heels in the squat exercises seemed biomechanically unsound . Some programs suggested incomplete range of movement exercises [36, 37]. Most articles on stretching used illustrations which, (like the wooden model mentioned previously) can be made to assume any position and therefore are less convincing than photographs; the one article which used photographs lacked any written explanations, which is potentially dangerous .
The inclusion of those practices once labelled as “fringe” in the biomedical model is a continuing trend. The survey of only the biomedical literature (I am excluding the chiropractic references here) suggests that Eisenberg’s remark, “We ignore, at peril to our understanding, the extent to which American patients seek out marginal practitioners (Firman and Goldstein, 1975) and obtain as much (or as little) relief as orthodoxy is able to provide for such chronic disorders as low back pain (Kane et al, 1974) [17:14].” may be even more appropriate now, as more patients seem to be availing themselves of such practitioner’s services. Hay in his concluding remarks at the W.A.I.T conference, left his audience with this admonishment:
This (the success of forcible manipulation) has seriously undermined the public confidence…If we honestly face the facts this attitude (open hostility) should cause no surprise. No excuse will avail us when a stiff joint, which has been treated for many months by surgeons and general practitioners without effect, rapidly regains its mobility and function at the hands of an irregular practitioner .
The only article on chiropractic to appear in a biomedical journal appeared with the note, “prepared by request”, suggesting that the article had been requested of the writer. The focus of the article was anatomical, with an emphasis on the sort of tests that should be performed by the chiropractor before manipulation, particularly in reference to a syndrome known as “vertebrobasilar accident”, the fatal severing of the cervical artery during a neck rotation. The tone was both scientific and reassuring .
There were two references to acupuncture. One mentions acupuncture in a range of treatments and notes that the, “skills of acupuncture can be acquired by most general practitioners with a short training course .” The other, written by a GP who teaches acupuncture, mixed a large number of esoteric terms, Chinese names of acupuncture points and biomedical anatomy. Subtle acupuncture techniques with which no GP would be familiar were named using traditional nomenclature, yet the article was not part of a series. No outline of acupuncture theory was attempted and the overall impression was confusing .
The review of hypnotic pain control and low back pain was interesting. Spinhoven  states that traditional biomedical treatments for back pain were developed on the basis of a “somatosensory” model, which assumed a direct relationship between pain and pathology. The absence of clear organ pathology has led to the development of a “multidisciplinary’’ approach, which considers psychological and social factors as well. Spinhoven notes that many authors consider that the absence of pathology and positive indications of psychosocial problems is a contraindication for hypo-analgesia, whereas patients presenting with psychogenic back pain may demonstrate symptom replacement (termed ‘displacement’ later in the paper), and only temporary or no pain relief. Spinhoven states that, “amazingly little is known that no researchers have demonstrated a clear relationship between pathogenic factors and back pain [70:120-121].”
Reviewing the use of a diverse range of psychometric instruments, he states that the tests produce “little useful information”, and he doubts whether this line of research is worth pursuing. He writes, “From a biopsychosocial perspective…organic and functional pain are conceptualised as forming a continuum [70:121].” He concludes that the “lively discussions” regarding the relative importance of psychosocial factors, their exact nature and whether they should be regarded as the cause of the result of back pain, are largely futile and he suggests that the emphasis should be which combination of procedures best suits the particular signs and symptoms [70:119-128].
Engel , three years before Spinhoven’s report was prepared, said that consideration of the patient (in social and psychological terms) must be made as well as any biological indices in the search for causes of illness; he termed this wider approach the “bio-psycho-social model”. He argued that this approach would tend to alleviate the current paradox wherein some patients who feel well are told that they are sick and others who are experiencing illness are told that they have no “disease” and hence are well [18:47]. Spinhoven does not cite Engle among his references.
An interesting result of one of the studies mentioned was that patients who claimed to have never suffered from back pain and who scored high on a depression scale proved four times more likely to develop back pain in the 1.5 years of the study than those with a low depression score and no history of back pain. This relationship was independent of presence or absence of disc degeneration [70:125]. The effectiveness of hypnosis and relaxation training appeared comparable [70:125].
Spinhoven  identifies a factor common to all hypnotic interventions: that pain experience can be influenced by means of a psychological procedure. This means that patients trapped in the dilemma of organic versus psychological pain require a translation process. He goes on:
Moreover, an approach aimed at modifying the experience of pain facilitates the establishment of a therapeutic relationship, because pain is the patient’s main complaint and is thus taken seriously. A therapeutic relationship centred around pain and its psychological consequences also seems to be a condition for allowing patients to discover for themselves that psychological factors can also give rise to pain [70:126].
Achterberg  also describes the efficacy of using imagery for pain control and cites a number of studies, including her own work in burn units [1:108-11, 138-9, 140, 151]. Moerman goes further and suggests that the construction of a symbolic image does not need to be reconstructed in another dimension of reality to be effective in healing; he says, in other words, that, “the construction of healing symbols is healing [52:66].
The only difficulty in a wider acceptance of these ideas would seem to lie in the promulgation of these techniques in a large and diverse industry whose, “Crisis stems from the logical inference that since ‘disease’ is defined in terms of somatic parameters, physicians need not be concerned with psychosocial issues which lie outside medicine’s responsibility and authority [18:37].” The underlying problem is the Cartesian paradigm and its mind/body division: so much research energy is spent in defining the difference between organic and psychogenic pain and not enough spent on how the various techniques could best be employed in the clinical situation.
One aspect of the therapeutic relationship that has been receiving considerable attention in the biomedical journals is the ‘sick role’. The fullest description of this role comes from Conrad:
The sick role has four components. First the sick person is exempted from normal responsibilities, at least to the extent necessary to ‘get well’. Second, the individual is not held responsible for his or her condition and cannot be expected to recover by an act of will. Third, the person must recognise that being ill is an inherently undesirable state and must want to recover. Fourth, the sick person is obligated to seek and cooperate with a competent treatment agent (usually a physician) [14:107].
The main concern of the biomedical writers is the problem of back pain becoming chronic and some feel that the various compensation schemes are counterproductive to the goal of resolving the problem. Currently, Conrad’s second and third conditions (that the individual is not held responsible for the condition and must want to recover) are being questioned. Bedbrook, talking about the difficulty in rehabilitating people with chronic back pain:
The most important and powerful method of stimulating motivation is that the patient should not be paid too much money for being off work…Man is a mercenary creature and as such, will accept most things for nothing if he is able to do so…there must be a stimulus towards recovery and towards employment and this stimulation, unfortunately, in many cases can only be of a financial nature .
Conrad reminds us that, “as legitimater of the sick role and as healer returning the sick to conventional social roles, the physician functions as a social control agent [14:108].” and this role is clear in rehabilitation and compensation. Quintner observes that, since the introduction of weekly payments at the 100% level, the actual amounts paid for any period off work has more than doubled. He added that, “41% of the 193 back injured persons remained unemployed and at least 28% of this population had not attempted or been able to attempt any employment at all.” Brook councils against the early use of radiological and laboratory testing, both because it is of little value in the acute situation and because it may encourage the adoption of the sick role. In addition he notes that the slower rehabilitation noticed in some groups in the community was related to fluency in English and not to country of origin, refuting the notion of “Mediterranean back ”. The results of the five-year study previously mentioned also supports the assertion that the popular stereotype of back pain sufferers as “litigious and hypochondriacal persons”, was completely unfounded and the respondents “not only generally continued to work in spite of the pain but they also ceased to receive medical or other treatment .” It is not clear whether the wider medical community shares this change in perspective.
Medical anthropology and back pain
The main challenges to medical care have been described as the new morbidity – functional disorders and chronic illness [17:10]. These are good general descriptions of back pain. As we have seen in the words of the biomedical writers themselves, biomedicine is not very effective in treating back pain. Hahn and Kleinman remind us that medical anthropology has developed various concepts that have had practical significance in clinical settings [30:327]; and that insight into one’s own fiend can arise from without it. In the following pages, I will argue that biomedicine’s lack of efficacy in treating back pain stems from its inherited epistemology and its continuing adherence to a rigid notion of the scientific model. I will try to show that in many cases, in adhering to narrow views of pathology and disease, biomedicine unwittingly creates many back pain episodes and the social conditions for its continuation.
Good and Good describe the predominant theoretical framework of biomedicine as the empiricist model of clinical reasoning; that is, that symptoms as described by the patient must be interpreted as the indicators or reflections of underlying somatic states and hence (for the doctor), achieve their meaning in relation to these states [26:170]. Such symptoms, although loaded with meaning from the patient’s point of view, are reduced to somatic variables in the search for pathology. In its simplest form, Good and Good’s principle is, “symptoms are irreducibly meaningful [26:191].” The clinical reality, as Hahn and Kleinman write, is somewhat different: It should be realised that in taking a “patient history’’, most doctors are not interested in the patient’s life world but in “diagnostic evidence”. This “interested distance” is described as “detached concern [30:316].” As Eisenberg states, patients suffer illness; doctors treat disease [17:11].
In consideration of back pain as a clinical phenomenon, it must be remembered that different cultures invest illness with entirely different significance and that this tendency is visible within a culture too. Good and Good offer the example of obesity in contemporary America, which is associated with a unique network of meanings in that culture – among them shame, embarrassment, implications of low status and lack of self control [26:176]. In contrast, Conrad speaks of the Pagopago Indians of the American Southwest, who bring their babies to the doctor for treatment if they are skinny, believing them to be sick [14:104]. Culture shapes disease first by shaping our perceptions and explanations of disease. Kleinman observes that psychiatrists in Chinese cultural areas have noted for some time that many Chinese patients present somatic complaints in place of psychological complaints [42:3-5]. This “somatisation” avoids the social stigma of mental disease (which can affect marriage prospects for generations) and allows the patient to assume a legitimated sick role. In writing about the sick role in general, the medical historian Sigerist observes:
Illness releases. It releases from many of the obligations of society, first from school attendance and generally from work duties. The sick person is relieved from many important concerns with which society demands the healthy busy themselves…(Sickness) also lessens the degree of responsibility or removes it entirely [48:43].
Thus, to paraphrase Good and Good – sickness is irreducibly meaningful, and a sore back can be a great deal more than just back pain.
Good and Good describe the back pain episode of a 28 year-old black American, wherein the patient and the doctor had quite different explanatory models: the doctor saw the problem as a muscle spasm, and the patient saw his problem in terms of a network of stressful experiences, including an over-stretched muscle in his back, being regarded as a malingerer, difficulties with his girlfriend, the stress of his mother’s current illness, financial problems, his being on probation and the status of not being able to work [26:183-4].
In the ubiquity and ambiguity of back pain as an illness experience, we can see the same processes at work: the patient is often seeking an explanation that considers as much of his world experiences as possible and an explanation that gives some meaning to the patient’s personal disorder; meanwhile the doctor is looking for pathology. Writing about therapy in general, Kovel describes a model that could help the general practitioner towards a better understanding of the chronic back pain sufferer:
The model for therapy is not the cure of a disease but the growth – more specifically, the education – of a person. In contrast to education as it is usually conceived, therapy takes into account the emotional and subjective needs and assumes an imbalance that has to be righted [45:46].
This process of education is implicit in Kleinman’s writing of the need for the doctor to translate across both the patient’s and doctor’s explanatory models . What I am suggesting here is that doctors tend to ignore the significance of the existence of the back pain itself and its meaning for the patient in the search for pathology. The all-important question should be, “What is the patient trying to tell me?” As Moerman put it, a wide range of psychological and sociological phenomena has been shown to correlate with a variety of physiological symptoms [52:61].
Taussig speaks of “reification”, a term employed to convey the process in which the patient’s symptoms (and eventually the patient) becomes “reified” or objectified. The human and social aspects of illness are stripped away, initially through the diagnostic and then the treatment processes and power over one’s body is abrogated to those in society whose responsibility it is to treat disease. I would like to extend this notion to include the process wherein a patient treats his own body as though it is an object completely separate from him; and where the patient is not responsible for its fallibility and capriciousness. This process is summed up in the phrase, “I’ve got a bad back.” Implicit in reification is the diminution and abrogation of responsibility for the condition. Taussig again, “Don’t contemplate rebellion against the facts of life for these…are locked in the realm of physical matter…To the degree that matter can be manipulated, leave that to ‘science’ and your doctor [78:6].”
Capra writes that the doctor’s role should be to make the patient aware of the context from which the illness arose. The recognition of the complex web of interrelated patterns which give rise to the condition is highly therapeutic, relieving anxiety and giving hope and confidence and initiating the healing process. Awareness of what past patterns helped give rise to illness gives the patient new insight and can lead to a change of those patterns. Capra notes that the fundamental role of the doctor is to teach; the word doctor comes from the Latin “docere” which means, “to teach” [13:335].
As medicine has advanced and become more scientific, it has lost its “unscientific” parts; some of this has been good and some bad. Kleinman writes:
Symptoms relief under medical care is the commonest outcome for most episodes of illness. Historically, this bonus to medicine as craft has been plague to medicine as science. The benefits patients have obtained have been attributed to the procedures in fashion rather than to the social dynamics of the medical encounter…such benefits have been labelled “placebo” effects [17:19].
The estimates of the effectiveness of the “placebo effect’’ vary from 30% to 60% [52:62]. According to Achterberg, the placebo is actually nothing more than granting (yourself) permission to heal; “it is a symbol the imagination can incorporate and translate into wondrous biochemical changes that are as yet beyond the comprehension of the finest scientific minds [1:85].” Moerman describes the same processes and states that the form of treatment as well as its content can be effective medical treatment; thus, medical treatment must be understood bimodally, in terms of its specific and its general dimensions [53:157]. Moerman here refers to a double-blind study of the effectiveness of the bilateral internal mammary ligation operation (BIMAL): both groups (those who had ligation surgery and those who had the operation but not the ligation) showed “substantial” relief from angina and reduced need for medication (actual operation, 66%; sham operation, 88%) [52:159-60]. Moerman ascribes the effects to placebo effect, following a “cosmic drama, following a most potent metaphorical path [52:161].” Other writers have described similar experiments and have ascribed the healing power to the placebo effect. Fundamental to an understanding of this effect is the notion of imagery.
“Imagery is the thought process that invokes and uses the senses: vision, audition, smell, taste, the senses of movement, position and touch. It is the communication mechanism between perception, emotion and bodily change [1:3].” In healing, imagery can work for or against the patient, “Belief kills; belief heals. The beliefs held by persons in a society play a significant part in both disease causation and its remedy [30a:16].” The interaction of belief and culture is an explanation offered for various phenomenon, from the extremes of the “voodoo death syndrome”, to faith healing. Achterberg continues, “Diagnoses are whimsical names, culturally determined and have very little absolute meaning or power in and of themselves. It is not the diagnosis that kills (or cures) but the expectations and images accompanying it [1:81].” The effects of a name are therefore difficult to separate from the name itself.
Torrey speaks specifically of the clinical effect of the naming process, termed the principle of Rumpelstiltskin, “The very act of naming (it) has a therapeutic effect…It says to the patient that someone understands, that he is not alone with his illness, and implicitly that there is a way to get well [81:16].” The reverse can also be true and the act of naming or diagnosing can have beneficial or harmful effects. The effects themselves have been named, “placebo” (from the Latin meaning, “I shall please”), and, “nocebo” (“I hurt”) [30a:17]. In the case of back pain and biomedicine, the author contends that the nocebo effect is far the more common and the more influential of the course of the illness, precisely because of the biomedical context, which says that any degenerative change to the vertebral structure of the back is irreversible. As we have seen, such somatic change is looked for, and most often is found. Thus the act of naming – “degenerating” or “extruded disc,” ”scoliosis,” “apophyseal joint dysfunction,” “spondylolysis” – and the like, are sentences of doom for most patients, because everyone knows that these are names of irreversible, harmful changes to the body; this is how our culture constructs this illness. Brooks suggests that, “Many patients regard pain as a manifestation of serious damage and this concept needs to be redefined .” When back pain is interpreted by the doctor as evidence of serious somatic change, what the author has termed the “reverse Rumpelstiltskin” principle is activated and the stage is set for the adoption of the sick role. Some never recover.
In dealing with back pain, medicine has painted itself into a corner: by insisting on pathology as the basis for most back pain and finding it, it can offer no course other than surgery (to change the pathology) or drugs (to cover the effects). Biomedicine admits that marginal practitioners are successful in treating back pain. One possible reason for this success can be found in the way they use positive imagery in their practise. Chiropractic will serve as an example. A brief description of the basic chiropractic theory requires an understanding of the biomedical concept, “dermatomes.”
In biomedical theory, nerves branch off from the spinal cord predictably and specific muscles and internal organs are innervated by specific branches of the nerves; the patterns of innervations are called dermatomes. The main significance of dermatomes for biomedicine is the prediction of the probable site of injury to the spinal cord following trauma. The term “neurological deficits” is used to describe such signs as a loss of feeling in a body part, or an inability to use a particular muscle, or a loss of bladder control and the like. Using the dermatome pattern, the physical location and severity of a deficit tells the surgeon which vertebral junction is likely to be involved.
Borrowing from the biomedical model, chiropractors have built an entire theory of medicine around “subluxations” and their relation to dermatomes, to treat illnesses of almost every kind. “Subluxations,” defined by Webster’s as a partial dislocation of a joint, are employed as an explanatory model of illness. A subluxation of a vertebra in relation to its neighbour is said to affect the segment of the spinal cord associated with it and hence the muscles or organ associated with that segment. For example, a stomach problem may be explained in terms of a subluxation of a particular pair of vertebrae, the manipulation of which will cure the problem.
In practice, the chiropractor runs his hand or a machine down the spine to locate any “subluxated” vertebra. He will always find one or two. The spine is then forcibly manipulated. A loud cracking sound results, which is audible evidence of the treatment in action. The chiropractor will again palpate the spine to determine whether the manipulation was successful. The patient will be told that the subluxation was the root cause of the problem. The patient is pronounced cured.
All of the healing elements mentioned in preceding paragraphs accompany such treatment: the cultural construction that says that chiropractors help people with back problems, the naming of the problem, the powerful accompanying image of a partially dislocated bone in the spine (which so appeals to our mechanistic minds), the sound that results from the manipulation which tells you that some physical aspect of your body has been changed, and so on. The sound of the manipulation (often called an “adjustment”) is a powerful metaphor for the healing process. If the cure is not immediately successful, you are assured that continuing treatment will fix the problem, in time. As the figures for remission of back pain suggest, this prognosis is most likely. Chiropractic is also practised preventatively.
Doctors too still rely on hope, faith and belief on the part of the patient [59:190]. If doctors are losing their charisma and becoming more prosaic figures like Myerhoff and Larson suggest, it would seem reasonable to expect to see a reduction in the efficacy of the placebo effect, in which, as Capra writes, the only active ingredient is the power of the patient’s positive expectations.
Worsley suggests, “It is now increasingly believed that they (doctors) know no more, often less, about the ‘non-medical’ dimensions of illness other than others…and invoke the authority of ‘science’ often only in order to cover up their own uncertainties and shield themselves against the demands and criticism of the layman [89:32].”
The placebo – that useful, “marginal” effect that has so long played a major role in healing and so long discredited –is however becoming the focus of medical researchers around the world in various fields: investigation into the clinical use of altered states, relaxation therapy, the field of psychoneuroimmunology, the use of images by athletes to aid performance and by the sick to help reduce pain and speed the healing process, and many others. In time through this work, the “unscientific’’ parts of medicine will be rejoined with the “scientific” ones. Capra sums up the process:
To reincorporate the notion of healing into the theory and practice of medicine, medical science will have to transcend its narrow view of health and illness. This does not mean that it will have to be less scientific. On the contrary, by broadening its conceptual basis it will become more consistent with recent developments in modern science.
“Essential to all therapies and counselling is the effect of the relationship with the therapist [45:48].” This fundamental aspect of health care will be found to be lacking in any medicine that focuses on pathology as the main cause of disease and in any medicine that focuses on disease rather than illness. Broadly speaking, these are the main problems of biomedicine today. Hahn and Kleinman, writing in 1983, have noted that, “The practitioners (and often patients) of biomedicine hold that medicine is separate from art, economics, religion, politics and morality [30:312].” It is no longer; there is an increasing awareness in the community of the shortfalls of biomedicine, especially in the way it deals with common illness episodes. With back pain, in the absence of serious neurological deficits, care should be taken to ensure that all non-invasive techniques are tried for its successful cure. This is as much the responsibility of the patient as the practitioner.
Surgery for back pain is one area where the placebo effect seems conspicuously to be lacking: only 30% or so of operations cure the symptoms. The author has suggested that this may be due to the “routinisation of charisma”, mentioned above, coupled with the nocebo effect (through the “reverse Rumpelstiltskin” process) and both added to the high probability that the original symptoms had other root causes.
It is suggested most strongly that, in the absence of neurological deficits, episodes of back pain should not be attributed to such powerfully negative images as “prolapsed disc” and similar, because, as the evidence suggests, a great many people with quite serious vertebral degeneration of various kinds are symptom free and with good back function. Instead, the doctor should say simply that the evidence is that most back pain episodes are self-limiting (the episode will have a finite course), and likely to be healed within a week or so. The doctor should advise a day or two of rest, followed by some gentle mobilisation exercises, perhaps under the guidance of a physiotherapist. The patient should not be encouraged to adopt the sick role. Medium and long-term strategies for rehabilitation should follow, with counselling and lifestyle advice given as appropriate.
Apart from surgery’s ineffectiveness as a means of curing back pain, the patient should make every effort to stay out of hospitals in any case, as they are potentially dangerous places: accidents in hospitals now outnumber all other industries except mining and high-rise construction and one in five patients hospitalised will develop an iatrogenic illness – fifty percent of these episodes resulting from drug therapy and ten percent from diagnostic procedures [13:149].
A preventative position
If back pain has its root in postural problems as some researchers have suggested, early screening of students while in primary and high school could prove extremely cost effective in the long term. This could be done in the same way that preventative dentistry is performed currently. Researchers have specifically cited such problems as “short leg” syndrome [22, 24, 25, 64], Scheuermann’s disease [31, 72], juvenile functional or structural scoliosis , and other back problems that are amenable to conservative treatment such as exercise, if detected sufficiently early. Techniques for detection of these problems need not be invasive.
Many anatomists, physiologists and surgeons have pointed out the vital role that the trunk muscles play in the support of the spine. Kapandji and others have shown that, if correctly recruited when lifting heavy objects, the abdominal muscles reduce the load of the spine by up to 50%, by turning the thoraco-abdominal cavity into a closed, pressurised cavity [39:108]. The abdominal muscles also flatten the lumbar curve, which as described above, has been implicated in many degenerative processes [39:107]. The paravertebral muscles play a powerful support role to the spine itself, also. All of these muscles may be strengthened by appropriate exercise. This is even more important in athletes involved in body contact sport [2,19-21, 28, 31, 35-40, 46, 54-56, 66-68, 82-83].
It was mentioned above that the lumbar curve arose through the transition from quadrupedal to bipedal movement and the lumbar curve resulted partially due to incomplete backward tilting of the pelvis on the spine. From clinical observation and experience, the author offers an alternative interpretation. Excessive lordosis (lumbar curve) can result from simple chronic tightness of psoas and iliacus muscles. These muscles, arising from the lumbar vertebrae and iliac fossa respectively, join and cross the hip joint anteriorly to join the femur; together they are powerful hip flexors. Of all the trunk/hip muscles, these have had to lengthen by far the most during evolution, and are often extremely inflexible. If this is so, and this inflexibility coincides with weak abdominal muscles, the lumbar vertebrae will be pulled anteriorly and lordosis will result.
As noted by Burnell, spasm in the hamstring muscle group can be misinterpreted as a positive Lasegue’s sign, or evidence of pressure on the sciatic nerve roots. He describes clinical experience where a few minutes of hamstring relaxation exercise shows an improvement of 20 degrees or more of hip flexion and, on retesting, no apparent Lasegue’s sign . The author can report many instances of a similar reduction in “sciatic nerve pain” in the clinical situation.
The author’s prescription for the majority of chronic back pain, then, is three-fold: strengthening of the abdominal muscles and a stretching of psoas/iliacus and hamstring muscles. Such a routine would take five minutes to do. It is also recommended that gentle stretching exercise be added to the curriculum of primary and high schools, along with the early screening described above.
The final suggestion in the management of back pain, whether acute or chronic, is the inclusion of stress-reduction techniques in one’s daily life. This will both reduce the incidence of chronic back pain and aid speedy recovery from an acute attack. Of all suggestions, this is the easiest to adopt into one’s normal routine: simply lie on the floor in front of the stereo covered by a blanket or the like and listen to soothing music for twenty minutes, everyday. This position is well supported in the literature [5, 22, 23, 69, 70].
Worsley quotes from the conclusion of the Mozambican statement of policy on health, “The creation of the system of primary health care is the top necessity in any country in the world…It is a rational and effective system of health under any conditions [89:345].” Capra writes, “Many reasons are given for the widespread dissatisfaction with medical institutions – inaccessibility of services, lack of sympathy and care, malpractice – but the central theme of all criticism is the striking disproportion between the cost and effectiveness of modern medicine [3:131].” Finally, the time may have come when the economic forces that helped to create biomedicine three centuries ago will push it in the direction of preventative medicine.
Capra ought to have the final word:
The first step in…self-healing will be the patient’s recognition that they have participated consciously or unconsciously in the origin and development of their illness and hence will be able to participate in the healing process. In practice, this notion of patient participation, which implies the idea of patient responsibility, is extremely problematic and is vigorously denied by most patients…they refuse to consider the possibility that they may have participated in their illness, associating the idea with blame and moral judgement. It will be important to clarify exactly what is meant by patient participation and responsibility [13:329].
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For the anthropology references I have relied mainly on the Medical Anthropology B26 reader, and a number of books. For references to back pain in biomedicine, I approached the National Library, and made my initial search through the microfiche index. I was looking for sportsmedicine references, as I have found that the latest developments in biomedicine tend to be used by sportsmedicine practitioners ahead of others. This may reflect the relatively young age of its practitioners. Some ten years’ worth of Physician and Sportsmedicine and American Journal of Sportsmedicine were searched, yielding 16 references to back pain. I then approached the Australian Medlars Service, and asked for a search of the Ozline database, some 39,000 books and journals, under the rubrics of back pain: (a)etiology, treatment, and rehabilitation. This yielded 81 references, of which I selected 17. I realised that the serach had not made any reference to either Australian Family Physician or Australian Journal of Medicine – a check with Ozline revealed that these two publications are indexed under the Medlars system (US sources). A further search of these two sources provided 12 relevant articles. Twenty-five books are listed in the references; some are secondary sources and some are quoted explicitly; they include works on anatomy and physiology, stress, kinesiology, and the clinical use of altered states. The articles retrieved by Medline and Ozline are grouped functionally below.
I have excluded analysis of the surgical techniques for the relief of back pain that form a large part of many of the articles, and have concentrated instead on the attitudes and assumptions of surgeons and others as revealed in their writing. Apart from a brief analysis of chiropractic in contrast with biomedicine, I have not included any reference to ‘alternative medicine’ and what it can offer to back pain sufferers. I have not attempted any analysis of the rationale behind stretching and strengthening exercise as either prevention or cure of back pain either.
In order to be able to recognise trends among the articles surveyed, I have grouped them by approach and content, from those that adhere most closely to a strict interpretation of the biomedical model to those that embrace a wider range of methodologies.
Anatomical studies of mechanisms of back pain: [16, 24, 60, 49]. Additional references not cited in the bibliography are found in , the low back pain conference in W.A.
Back pain in general and surgical practice: [9, 22, 32, 33, 41, 50, 55, 56, 58, 70, 72, 77, 81].
Postural aspects of back pain: [2, 11, 24, 64]. The reader will notice that three of the four references cited appear in the Journal of Australian Chiropractor’s Association; this form of medicine is by no means universally accepted as part of biomedicine.
Back pain in the workplace: [10, 61].
Back pain in athletes: [7, 27, 28, 31, 66, 71].
Stretching techniques for muscles and joints related to back pain: [4, 57, 75, 86].
Strengthening techniques for muscles related to back pain: [19, 20, 21, 35, 36, 37, 40, 82, 83]. Articles  and  have an emphasis on rehabilitation, and some of the techniques included are not accepted as part of biomedicine by most reserachers.
The reader will notice that, of the articles retrieved by Medline/Ozline, none predates 1980. Of the other relevant articles, none was written before 1974, as I have endeavoured to make my focus historically broad, rather than deep. However, in this modern literature there are a number of interesting references to previous eras in biomedicine.
Pro-Active Occupational Health and Safety
Prepared for the inaugural COMCARE National Rehabilitation Conference; Canberra, November 2003.
In this paper, I argue that the standard definition of “rehabilitation” is fundamentally flawed, and in need of a major overhaul.
In this brief note, I wish to raise a few points for discussion at the inaugural Comcare National Rehabilitation Conference. Specifically, I wish to discuss whether there might be new opportunities to revisit what ‘Occupational Health’ can look like in the 21st century and what the implications for prevention and rehabilitation of common workplace problems might be if these suggestions are facilitated.
This paper will concentrate on broadening the definition of occupational health by considering aspects that are given low, or no, priority presently. The paper will argue that a widening of the traditional OHS focus – moving from focussing on treatment or rehabilitation to an explicit preventative perspective (which includes treatment and prevention) will better serve employers and employees alike, with benefits to both. I note here that the Australian Government operating environment continues to change and that risk management strategies are being built into its activities explicitly. This trend may provide the motivation to update the OHS legislation, or, perhaps, simply the focus of its implementation. In addition, I will consider a few examples of what appear to be contradictions between ‘duty of care’ and the rights of individuals. Finally, the paper will identify a number of potential ‘pressure points’ in the present system, via which change, if desired, might be effected
I speak for a small organisation which has been active in pursuing ‘organisational health’ in a few different ways: by working with individuals in group situations, by providing lunchtime seminars on a wide variety of health-related topics, and by working one-on-one with individuals with identified problems in a clinic environment. From many conversations with the participants of these classes, and with patients in the clinic, I wish to discuss how both ‘rehabilitation’, the OHS (CE) and SRC Acts are implemented presently from our perspective. This note is not intended to be a rigorous examination of either the legislation or its implementation – it is more of an ‘impression piece’, to facilitate ideas generation and exchange at a forum that is likely to provide ideas and, possibly, visions of how the future might unfold.
What does OHS look like?
Reduction of potential risks to health in the workplace is the main focus of OHS today, and to some extent this probably reflects the history of successful workplace claims on the insurance industry by injured employees, and ex-employees. In the ‘standard’ office environment, this means that an OHS officer’s time will be spent in determining the extent to which provisions of the Act are being met, and in actively improving the workplace with respect to the same provisions. Depending on the nature of the workplace, this may mean intervention strategies such as ensuring optimal desk-to-wrist-support height, optimum screen height, assessment of the suitability of the office furniture (with a view to reducing the likelihood of OOS or neck pain), and so on.
In a workplace where manual labour predominates, the focus will be on determining the extent of conformity to accepted safe handling practises, reduction of gross risks in the environment, the teaching of safe lifting techniques, and the implementation of increased use of mechanical devices (with a view to reducing the likelihood of lower back injuries), and similar.
An unfortunate consequence of pursuing this approach is that OHS officers are sometimes seen as training people to think like victims; encouraging staff to see the workplace as inherently ‘dangerous’; and even seen to be driving a wedge between management and staff. A ‘victim’ mentality sees change as management’s role, even where needed changes can only be achieved by the individual. Examples include giving up smoking, eating properly, doing indicated physical and relaxation exercises, and so on. OHS may be thought of as ‘old’ legislation – now there is an opportunity to revisit and reinterpret with respect to current and emerging needs.
Fitting workplace to employee
One deep assumption of the relevant legislation seems to be that the workplace should be optimised to fit the employee, and in respect of workplace hazards, this is a very respectable goal. Nothing in the Acts, however, constrains wider interpretations of what ‘occupational health and safety’ and ‘rehabilitation’ could mean in the future. What I am speaking about is how the legislation is enacted in workplaces everywhere, and is probably a reflection of the speed of natural evolution in these matters. The very natural human trait of risk aversion has led, on occasions, to OHS being viewed as a ‘spoiling’ operation, telling employees what they can and cannot do. This can give rise to the impression that there is a strong emphasis on physical aspects of the workplace (like height of electrical outlets, for example) and perhaps insufficient focus on the larger picture (whether particular officers are simply being required to work too many hours – no matter how ‘safe’ the environment, for example).
Fitting employee to workplace?
OHS managers and staff have done significant work in the past 10-20 years in instituting thorough processes to minimise workplace accidents. No doubt there is more work of this sort to do, but the returns on this focus are likely to diminish. Now is the time to reassess what ‘risk management’ might look like in the 21st century. It will involve taking a fresh look at the notions of spreading risk and responsibility. It will involve a reinterpretation of the idea of ‘duty of care’, and will explicitly provide employees with access to preventive techniques which allow them to take care of themselves and, as a result, enhance their productivity and wellbeing. This form of risk management will avoid the familiar problems associated with identification of risk factors, by instead encouraging processes of education that help all employees (and managers!) to ‘self-identify’ and engage in processes that minimise the risk factors, expanded upon below.
Current best practice in risk management requires that risk be spread over all the ‘players’. Presently, risk management seems to be biased toward the employer. I suggest that risk management needs to be expanded to the employee equally, in a transparent, negotiated, and incremental fashion.
Redefining risk management will involve redefining ‘training’. Presently, employees are granted access to training in all areas that may affect their capacity on the job, but there are interesting contradictions. For example, it is commonplace for employees to take multiple days off from the workplace at considerable expense to attend training on how to operate their computer. Rare indeed, however, is teaching employees how to ensure their body and mind can function optimally so they can sit comfortably and safely at a desk for extended periods to operate that computer!
In this vein, it needs to be noted that human beings are expert at mobilising the ‘fight or flight’ response; this is well accepted and well documented in research. The fight or flight response served our ancestors well, but it may have outlived its usefulness in the modern workplace. Instead, the time has come for the complementary response, named the ‘relaxation response’ by Benson in the 70s, to be encouraged and developed. The capacity to relax in stressful environments (accompanied all the while by the mantra of ‘working smarter’, ‘doing more with less’, etc,) will confer its own evolutionary advantage, in terms of ‘managing upwards’ and effects on staff, and in terms of improved capacity to discharge excess tension (to reduce health risks).
Improved stress handling capacity is well correlated with improvements in general state of health, and so is easily able to be identified as being in the interests of both managers and employees alike. At the same time, managers need to realise that there are limits to what this approach can do: managers and employers alike need to take annual leave and work the accepted best practise number of work hours each week! Insistence on this basic principle helps ensure a healthy balance between work and non-work activities, and is an explicit endorsement of the principle that leisure activities and family life contribute very significantly – positively and negatively – to risk management in its broadest sense. As an aside, if this out-of-work-time dimension is to be factored in seriously, it needs to be out there ‘on the table’: for discussion and comment.
This discussion and comment, in addition to being a major part of culture shaping, is essential if any recommendations are to be implemented: nothing is more irritating to any of us than simply receiving instructions from above on where we are going to go – especially if this involves a major change of direction.
Indicators of risk
In addition to the stress aspect, advances in body work in the last ten years have recognised a number of indicators of likelihood of common workplace injuries like neck and back pain, and OOS. Identifying patterns of physical flexibility and the location of held tension can help the manager and the employee to avoid, or minimise, these problems. Reducing differences in range of movement (ROM) of the soft tissues and skeletal structures in a left-right sense in an individual’s body (with reference to their tighter side) is more effective in reducing risk than the conventional screening processes, and has the advantage of avoiding any stigma of how an individual ‘measures up’ in respect of some external idea of normal or desirable function.
Reaching all employees
On-going education programs in work time are suggested as one way of helping managers and employees become aware of risk factors associated with lifestyle choices. These programs will only be maximally effective in leading change if provided in work time, like other accepted education programs, through normative association processes. Too often, worthwhile seminars offered in lunch times only ‘preach to the converted’. Programs need to include wide perspectives on nutrition that help the employee make sense of the conflicting information from research and the popular media. In this context, managers will need to look carefully at the implications of the provision of standard fast food and drink vending machines in the workplace – what sort of signal do these send? Consistency of perspectives is essential, and there may be opportunities here to forestall future vexatious litigation.
Extending ‘duty of care’
The practise of smoking needs to be discussed briefly here. Fifteen years ago, smoking in the workplace was widespread and its banning was controversial. It is suggested here that within similar timeframes the widespread practise of employees being able to take regular breaks in work time to smoke outside buildings will stop. I believe that this change can be achieved non-legislatively. It will be achieved by a more consistent interpretation of ‘duty of care’ by management, and so doing may reduce the risk of future litigation.
Top-down and bottom-up
At this workshop, it will be interesting to explore the ways governments may require the present legislation to be interpreted to achieve this end; my feeling is that any top-down approach will need to be balanced with a bottom-up push from employees and their representative groups, to ensure that any expansion of the OHS role is not perceived as ‘big-brother’ at work.
What can be done now?
While I acknowledge the advantages of the “no fault” provisions of the SRC Act in terms of providing all possible assistance in returning to work as quickly as possible, I suggest that everyone involved in rehabilitation will benefit by shifting attention explicitly to from rehabilitation to prevention. An expanded and operationalised understanding of ‘prevention’ will include treatment and rehabilitation as options if prevention fails. A matter to be addressed in this context is the present interpretation of ‘rehabilitation’ to mean “returning an employee to a pre-injury state of fitness”, as a number of speakers at this conference have claimed. In the case of the common overuse injuries, the problem must be obvious: the pre-injury state of fitness was exactly what allowed the injury to arise in the first place.
The ease with which the shift from rehabilitation to prevention may be achieved will depend partly on the extent to which employers are seen to be fulfilling their duty of care responsibilities in terms of insistence on reasonable work hours and strongly encouraging employees to use their recreation leave.
Prevention will require a sober assessment of risk factors. These will include obesity (so, consideration of overall nutrition), habits such as smoking and recreational drug use (including alcohol), lifestyle choices (in all ways – some recreational activities pose risks of far greater magnitude than any in the workplace; similarly, no exercise at all poses risk too), and so on. The emphasis will be on a broad, open approach – workplace risk factors will thus be able to be better balanced with non-workplace factors. Rehabilitation will continue to be available regardless of how an injury occurred.
Self-help as complement
Complementing this shift in focus will be a broad range of self-help approaches – offered in work hours for employees to feel that management is serious about helping to change the work culture in directions that are acceptable to all. These will form part of the demonstration of duty of care I spoke of above, and will highlight the shift in focus from treatment and rehabilitation to prevention. These approaches will include the teaching of relaxation techniques, the facilitation of stretching exercise classes in the workplace (locating suitable venues, issues of access from neighbouring departments, and so on), presentations on nutrition where aspects like effects of foods and drinks on state of mind are discussed, and other health-improving presentations.
The P&F approach
The Posture & Flexibility organisation has been running “Pro-Active Occupational Health” classes on-location for the APS for over five years now in APS departments, including Customs, DOTARS, Health, DAFF, DFAT, Attorney-General’s Department and many others. We have been presenting lunch-time seminars on nutrition and relaxation/meditation techniques over the same time frames. P&F produces a wide range of multi-media to support these activities and has full production capabilities in-house to produce material to order to the specific needs of any department. P&F has the capacity to train interested OHS officers who would like to teach this material in their own workplaces, following a suitable training period. Health optimisation is our goal.
The APS P&F classes are self funded in most instances. Some departments fund a percentage of the cost of the classes; we recommend no more than 50% of the cost if this is done. We believe that, presently, attendees benefit from the explicit commitment that paying implies: attendance at free classes – despite the same material being presented – diminishes over time compared to the paid, or subsidised, classes. This ‘spur’ will become unnecessary as the culture changes.
HR officers in the APS departments where our classes have been running have informally tracked the participants and compared with suitable cohorts, and report the following:
- Reduced days off work
- Reduced injuries (especially low back pain, OOS, and neck pain)
- Full recovery from existing similar problems
- Experience using our methods in non-APS workplaces (for example, ComSteel in Newcastle) have helped organisations maintain their self-insuring status.
- The use of P&F techniques in the workplace has reduced insurance payouts in local companies.
We believe that a wider-scale implementation of these methods will allow organisations to argue for reduced insurance premiums (in a similar fashion to the distinction made between smokers and non-smokers presently), in time. The argument will turn on demonstrations of duty of care.
Finally, no note on this subject would be complete without mentioning the incredible social and financial costs to government and industry of just three compensable injuries: low back pain, neck pain, and OOS. These are just symptoms of organisational ‘ill health’.
I suggest a strategic task force to help bring about these changes, drawn from the participants of this conference. Helping to move organisational cultures along the recommended lines can only bring real benefits to the workplace, and will be exciting and important work. Let us consider a strategy for the next 10–20 years, and achieve a future we help design rather than one we inherit.
Hidden causes of back problems
Hidden causes of back problemsJournal of the Royal Australian College of General Practitioners.
This is a technical article on the ‘hidden’ causes of back pain, written for doctors. Referenced.
In this note, I wish to share the results of workshops I have been running around Australia since February this year, 2000. These workshops offer the approach to treating neck and back pain outlined in the book [Overcome Neck & Back Pain (Simon & Schuster, revised 4th edition). The book advocates a structural analysis followed by a functional analysis, and treatment using an exercise-based approach. Approximately 1,350 people have attended the various workshops to date. All were long-term neck or back pain sufferers, all of whom had sought treatment previously from physiotherapists (around 30%), doctors (35%), chiropractors and osteopaths (over 60%), and a variety of other treatments. Most had sought treatment from more than one kind of practitioner. In the vast majority, any relief had been temporary (a day to a few days the most common response) and most participants expressed the desire to learn how to look after themselves, preferably freeing themselves from the necessity of seeking regular treatment.
In order of significance, the most important causes of back pain identified have been an actual leg-length difference, with or without tight iliopsoas. These muscles have been found to be tight in absolute terms (45%, using the standard test, following Kendall) or tighter on one side (55%; this includes a proportion of the previous figure). In order of frequency, the muscles in which the pain is experienced are quadratus lumborum and erector spinae when the pain is lower back and one sided, between the hip and the spine (around 60%), the fascia into which latissimus dorsi inserts when the pain is lower (10-15%; including sacro-iliac joint and ligament pain), and piriformis, about which more below. With respect to neck pain, the most significant cause and source of pain is levator scapulae, and the most important cause of referred pain in the arm and hand have been found to be the scalenus group.
Muscles, nerves, and pain
The assumption of the workshops is that the main sources of dysfunction (both in reduction in range of movement and pain) are the muscles (and sometimes nerves) of the body. The further assumption is that the pain is a combination of inaccurate body image (by this I mean that the stretch reflex is triggered inappropriately early in the range of movement, for a variety of reasons including protection patterns held over from an earlier trauma or other causes) and muscle tension, also deriving from a variety of causes, to be addressed below. Following the structural analysis described below, stretching exercises (or parts of standard exercises) are used diagnostically to compare key functions. In the vast majority, the location of the pain is in the tighter of paired muscles. Whether this is a result of pathology or is itself a pathology is a question to which I’ll return. Treatment consists of precise stretching exercises, usually parts of conventional exercises, using the Contract–Relax (C–R) approach to increase range of movement, reduce muscular pain, and to remake dysfunctional patterns and body image.
Pathology: a second look
One further assumption is that pathology identified in any reports brought along by the participants is not of the severity wherein surgical intervention is either recommended or likely to be effective. Most participants with sciatica, for example, have been told that the severity of any identified pathology did not indicate surgery. A small number (4 individuals; n=1,180) were seeking to avoid surgery. A significant number (110 individuals; n=1,180) had been informed that no significant pathology could be identified to explain their problems, and the most common recommendation in these cases was to seek a pain control clinic, or to use relaxation techniques or similar to learn to live with the pain. It is now well known that disc and joint pathology is normal, in the sense that two-thirds of a researched non-back pain suffering population displayed prolapsed or bulging discs, or serious joint pathology. Many had pathology at more than one vertebral junction. The researchers concluded that had any of these people been suffering back pain and had gone to their doctor and had the MRI analyses done, the conclusion would have been that the pathology identified was the cause (Jensen et al., 1994). A similar study a few months later for the neck showed virtually identical percentages. It is clear that pathology may exist benignly. It also seems possible that other causes may render pathology significant (in the causal sense), and one task is to identify such mechanisms. An actual leg-length difference is one such cause.
Leg-Length Inequality (LLI)
The workshops are providing evidence to support the claim that leg-length difference is significantly over-represented among back and neck pain sufferers, compared to the results of various studies done over the last 20 years. The standard figures are that 10–14% of the population have a leg-length difference of 9-10mm or more (see, for example, Giles & Taylor, 1985 or Rock, 1988). From the raw data provided in the radiological studies considered, calculation shows that differences in leg-length of 5mm or more are found in around 55% of the general population. Until now, the assumption has been that differences less than 10mm are unlikely to be significant. My work with athletes over the last ten years has suggested that smaller differences can be highly significant, this perspective being based on the displayed asymmetrical muscular development that cannot be attributed to any asymmetry of patterns of use. Such athletes demonstrate additional development in erector spinae on short leg side and additional development of the paravertebrals in thoracic spine opposite short leg most commonly, evident in athletes whose sport or training is primarily performed in the vertical load-bearing position. The inference here is that the body can be considered a ‘map’ of the forces that have acted upon it, and that a visual comparison of the shape of the muscles permits conclusions to be drawn about how the individual’s body uses itself. In one notable example, an experienced triathlete with a barely-discernible leg length difference (two or three millimetres) displayed clearly visible differences in the muscles mentioned. His weekly training schedule included 140–160km running. In a symmetrical activity like running, symmetrical morphology is expected. If asymmetrical morphology is found, one question to be answered is what forces might have produced the asymmetry.
In the workshops we have seen similar asymmetrical development in the majority of attendees, few of whom have been athletes, and on questioning the vast majority did not regularly engage in asymmetrical activities. On testing (outlined below) around 75% displayed a tilting of the pelvis in the coronal plane, and many displayed a subtle recapitulation of the three normal curves of the spine in the coronal plane following the obliquity. This is Travell and Simon’s ‘S’-shaped adaptation. The ‘C’ shaped adaptation (see Travell & Simons, 1992, p.54) appears to be much less common, and is found more often in individuals whose whole-body flexibility is poor. The assumption is that tilting of the pelvis (with consequent alteration to the ideal relation of the spine to the forces of gravity) is the significant factor, which may be due to factors other than uneven length of the bones of the leg. This distinction is made because at least three causes of pelvic obliquity are not usually considered in measurements of leg length (a single pronating ankle, asymmetrical placement of hip joints in pelvis, and small hemi-pelvis). Additionally, hip width may be significant, as any particular leg length difference will tilt the pelvis further in someone with narrow hips. For these reasons, and the need to see how the body resolves the forces of gravity in the anatomical position, we favour a standing test of leg length. Many factors can vitiate lying leg length tests, a position elaborated in chapter eleven of my book.
The ‘Eyeballing’ approach to assessment
At the workshops, we begin with visual inspection of the whole body, looking for ankle pronation, symmetry of hips with respect to shoulders, level of shoulders, and placement of head. Comparison of left and right waist indentations are useful for women. We than ask the participant to stand with a small plastic block of 12 mm thickness under each heel in turn. When the block is under the longer leg, the distortion to the symmetry is obvious, both to observers and the participant. When placed under the shorter leg, the patient looks and feels more balanced. If the use of the block causes equal or similar distortion to the shape of the body on both sides, no significant difference is the conclusion. If a difference is found, a heel lift correction of just less than half the estimated difference is recommended. The reason for not recommending correcting the whole of the estimated difference is that we do not wish to render and adaptations made by the body possibly maladaptive. The thickness of the correction can be increased at later date if its use appears to help the problems; more likely if the attendee’s work is performed in the vertical load-bearing position.
One relationship between strength and flexibility
With respect to asymmetrical morphology of the muscles of the lumbar and thoracic spine, one additional observation needs to be fleshed out. Over the 18 years of running stretching exercise classes at the Australian National University (around 200 new students per semester), we have found an inverse relationship between strength and flexibility. For example, in the normal healthy pain-free adult, the standard tests of shoulder flexibility have revealed that the vast majority of right-handed people have reduced shoulder joint flexibility in all planes of movement. As far as the whole body is concerned, if the flexibility of any paired muscle group is measured, we have found that (in the individual who does not include stretching exercises in their normal routine) the stronger or visibly better developed muscle usually tests tighter. With respect to individuals who display asymmetrical muscular development following pelvic obliquity, we have found that the main loci of one-sided low back pain in the majority corresponds with the tighter half of certain pairs of muscles. Quadratus lumborum and erector spinae, and occasionally the obliques and the inferior-most fibres of latissimus dorsi are involved. In the majority of patients, the pain has found to be located in the tighter of a pair of muscles.
Tests of functional flexibility
Following structural analysis, four tests of functional flexibility are performed by the group, in pairs. Working in pairs facilitates good form in the tests, and teaches the participants how to correct the body’s natural tendency to avoid stretching the muscles that are tight. The tests are right/left rotation, right/left hip flexion (with both bent and straight legs), right left/lateral flexion, left/right hip extension, and left/right piriformis.
Improving the Straight leg Raising Test (SLRT)
If the attendee complains of sciatica, a supine straight leg-lifting test is performed and followed with a suitable piriformis exercise. The straight leg-lifting test is then performed a second time. What is most often found is that the leg can be moved further into the ‘normal’ range (usually reckoned to be in the 65–70 degree range in this test), and that the pain that was associated with the sciatica is now felt in the calf (less often, the hamstring). An additional stretching exercise is done for the indicated muscle, and the limb re-tested. In the majority of cases, the person who had been diagnosed with sciatica can allow the limb to be moved into the normal range after these exercises have been done. This approach can reduce false positives in this common test.
The most often found pattern of flexibility associated with a leg-length difference are hip and hamstring muscles test looser on the shorter leg, rotation of the lumbar spine looser when the shorter leg is taken to the floor in the ‘lumbar roll’ test, lateral flexion is tighter away from the short leg side, and the hip flexors are tighter on the short leg side. These patterns are not immutable, however, and we advise attendees to identify their own patterns and treat these, by beginning their stretching workouts with the tighter of the pairs, and finishing with the tighter pair and thus doing more work for these muscles over time.
Specific muscular causes
We have found tight hip flexors correlated with central low back pain, and a single tight hip flexor correlated with one-sided quadratus lumborum pain. As mentioned, the tighter hip flexor is usually found on the short leg side, but this is the least robust of the patterns. Tight hip flexors have been found to be highly correlated with an increased lumbar lordosis, often in association with bilateral tightness of quadratus lumborum and erector spinae. If the hip flexors (iliopsoas and rectus femoris) are tight, the leg will not extend past the line of the body (as is needed when walking, for example) without rotation of and/or anterior tilting of the pelvis. A suggested mechanism for pain in these patients is increased pressure on the facet joints together with the muscular causes mentioned. Lumbar flexion exercises usually provides immediate relief of the pain. Long-term tightness may contribute to increased kyphosis and additional compensating cervical lordosis, caused by the body’s need to carry its weight over the balance point. Effective stretching of the hip flexors is difficult: unless the trunk is braced, as stretching these muscles extends the lumbar spine, frequently eliciting the participant’s pain.
Another often-unsuspected cause of back and hip pain is one of the external hip rotators, piriformis. In about one fifth of the population, the peroneal branch of the sciatic nerve passes directly through this muscle rather than passing inferiorly to it (Travell & Simons, 1992, vol.II, p. 186 ff.). If this muscle is in spasm or simply very tight, enough clamping force can be produced on this branch of the sciatic nerve to cause pain in the muscles behind the hip joint and sciatic pain down the back of the leg. Typical histories include long periods of sitting.
This pain can feel the same as sciatica caused by disc impingement and difficult to distinguish from it from symptoms alone. If the patient has disc pathology a diagnosis of nerve-impingement induced sciatica may be made without there being any casual relationship between the pathology and the symptoms. I have developed an effective test and stretch for this area and, on average in past workshops, up to half the people present demonstrate this problem. The relief can be immediate and dramatic. See exercises 5, 6, and 7, and a practitioner-applied version, 16, in the book. In a future note, I shall consider the role of leg-length inequality and patterns of muscular tension in neck pain, and referred pain phenomena such as RSI and carpal tunnel syndrome.
Giles, L. G. F. and Taylor, J. R., 1985. Low-back pain associated with leg-length inequality. J. Aust. Chiropr. Assoc., 15: 135-145
Laughlin, K., 1989. Low back pain: review and prescription. In Is our future limited by our past? Freeman, L. (ed.). Proceedings of the third conference of the Australiasian Society for Human Biology. The Australasian Society for Human Biology, University of Western Australia
Jensen, M. C., Brant-Zawadski, M. N., Obuchowski, N., Modic, M.T., Malkasian, D., and Ross, J. S., 1994. Magnetic resonance imaging of the lumbar spine in people without back pain. New England Journal of Medicine, July 14. 331, No. 2: 69-73
Kendall, H.O., Kendall, F.P., and Wadsworth, G.P., 1971. Muscles, Testing and Function. 2nd edition. Williams and Wilkins, Baltimore. Rock, B. A., 1988. Short leg-a review and survey. J. Aust. Chiropr. Assoc., 18: 91-96
Travell, J.G. and Simons, D.G., Volume1, 1983; Volume II, 1992. Myofascial pain and Dysfunction: The Trigger Point Manual. Williams & Wilkins, Baltimore
Hidden muscular causes of neck and back pain
Abstract prepared for Chiropractic & Osteopathic College of Australasia Conference, November 1999
The three ‘big ones’ are considered here: piriformis, quadratus lumborum, and levator scapulae.
Tight or inflexible iliopsoas can alter the biomechanics of the lumbar, thoracic and cervical spine. When in the vertical load-bearing position, tight iliopsoas prevents the pelvis from sitting in what might be considered a ‘neutral’ position; excessive lumbar lordosis can be the result. In concert with an anteriorly-tilted pelvis, the thoracic curve (kyphosis) increases; similarly the cervical lordosis increases in an attempt to maintain the weight of the head over the body’s centre of gravity. Kapandji (1974) suggests that the ideal position of the pelvis is one that produces a shape in the spine that which requires the least muscular effort to support. Standard stretching exercises for the hip flexors are often ineffective, extending the lumbar spine and aggravating the problem in many instances. Appropriate bracing techniques will be demonstrated.
Piriformis syndrome is generally taken to describe the condition when a large or tight piriformis entraps the common peroneal or tibial portions of the sciatic nerve between piriformis and the greater sciatic foramen (Freiberg described a surgical operation to relieve this phenomenon as long ago as 1934), or when part of the sciatic nerve pierces piriformis. All the standard indicators of disc-induced sciatica can be mimicked by this condition. It is generally accepted that in 10-20% of the population (Travell and Simons, 1983), the common peroneal portion of the sciatic nerve pierces piriformis , but recent research from Japan suggests that this range is conservative. In a study of 450 pelvis halves, Chiba et al., 1994, identified eight additional variations on how portions of the sciatic nerve may pierce piriformis and suggested this may occur in up to 37% of the population. Three effective stretches for this muscle will be demonstrated.
Quadratus lumborum is a common site of the pain of low back pain. The causes of pain in this muscle are varied and will be discussed. Quadratus lumborum is commonly associated with actual leg length differences (and may be in the induced cases, too) so effective stretching exercises can be a helpful adjunct to other therapies.
Levator scapulae is a common source of neck pain and dysfunction. Tightness in this muscle is frequently associated with scalenus tension. The anatomy of levator scapulae suggests that no single exercise can stretch all its fibres; a combination of lateral flexion and flexion combined with lateral flexion is required. The scalenus group (anterior and medial) have been suggested as the cause of Thoracic Outlet Compression Syndrome by many authors, but stretching these muscles presents the practitioner with special difficulties. Unless levator scapulae is sufficiently relaxed, putting the neck into the sort of rotated and extended positions that will stretch scalenus, the neck may spasm. Stretches for both these muscles will be shown.