Low back pain

My encounters with patients, colleagues and conventional medical practitioners is punctuated by fragmented and web-generated info-bytes, self-assessment and DIY interventions. By necessity much of my effort in consultations and professional interactions is to understand peoples causal and diagnostic narratives. These can range from accurate and coherent to dangerously erroneous. Patient and practitioner desperation around both a simple explanation and intervention for low back pain, particularly chronic low back pain, has driven ‘core’ based fitness industry product and underpins much musculoskeletal practice.

My sense is that at least 80% of my patients identify core weakness as contributing to both the causation and self confessed failure to recover from low back pain. This revelation provides an opening to discuss with patients the idiosyncrasies and innumerable subtypes of chronic low back as well as the shortcomings of many purportedly evidenced-based interventions. In this process we navigate beliefs and myths as well as fashion alternate causal narratives and therapeutic paths.

This post is not an overview of the pathogenesis low back pain or a treatise on motor control patterns or a tale good basic research warped and transformed into fitness and rehabilitations product. Rather this post will explore the interplay of these factors in osteopathic practice.

Rigid and altered motor control is evident in patients experiencing chronic low back pain. These motor control patterns often persist in the absence of pain – blending into a spectrum of pain avoidance behaviours. Many low back pain patients are recommended by increasingly time-poor ill informed GPs,  to engage in purportedly rational, evidenced-based and biomechanically informed core training. My observations and experience is that these interventions unwittingly mimic, amplify and reinforce dysfunctional patterns of motor excess. The compounding effect of misguided core training on rigid motor control produces a state that reminds me of an animation where this little crustacean states ‘my carapace is killing me’.

The mutual desire of patient and practitioner for a simple causal narrative and active therapeutic pathway has driven this curious interplay and therapeutic theatre in which intervention reproduces the dysfunctional patterns associated with chronic low back pain. The desire for a simple causal narrative is demonstrated by its persistence in spite of mounting contradictory evidence and experience.

The causal narrative goes something like this – ‘my core is weak and that why I have low back pain’. Implicit in this narrative is usually some idea about instability. Overlaid on this are usually some notions about posture. All aspects of this causal tale are conjectured and overly simplistic, particularly if we consider chronic low back pain as a heterogeneous entity (consisting of subgroups) – at least as varied as our patients idiosyncratic therapeutic responses.

From location to function

The core, like other dissected anatomical regions is a construct and explanatory tool – a term of convenience. (Dys-) function does not respect topographic anatomical boundaries. The musculoskeletal system has a capacity for adaptation and self-organisation that challenges a regionally compartmental view of function and anatomy. At a neurological level the brain maps function and movement not muscles. Adaptation to pain involves the propagation and assimilation of injury. Inertial dysfunction may drive compensatory movement elsewhere whilst instability might necessitate regional and even systemic rigidity.

Pain irrespective underlying segmental inertia or instability promotes rigidity, altered resting muscle tone and motor control, elevated sympathetic activity, diaphragmatic and accessory respiration and changes in neuroendocrine regulation. Local or systemic inflammation adds further complexity to this scenario. Detailed first person accounts of the complex effects of pain undermine the conceptual category of core and brings into question the faith that core training alone could be therapeutic in chronic low back pain. Pain is a systemic experience that is more than merely local changes in somatic afferents and efferents.

From rigid to dynamic stability

Ideas are infectious – memetic. The elegant simplicity of cooker-cutter core stabilisation in all instances of chronic low back pain is alluring. The anatomical and neurophysiological connections between deep spinal muscles and transverse abdominus appear to sure up the case that core stabilisation is a legitimate and rational intervention. Occam’s razor is sometimes a principle of blunt and simplistic self harm. The fact is that the therapeutic effects of core stabilisation in chronic low back pain are indistinguishable from the benefits of general exercise.

Appropriate and natural engagement of the core emerges through complex biologically realistic movements, promoting interregional coordination and providing a rich sensory experience, competing with pain in a patients overall neuro-ecology. The core by contrast is a bore. The isolation of this region and the prescription of elevated and sustained transverse abdominus contraction impoverishes movement, reduces spinal stability, connectivity and resilience – promoting a rigid and low-dimensional stability.

Natural movement practices are generally open kinetic systems that drive dynamic stability and utilises passive and active elements. It may seem that such movement is a more nebulous aspiration and more difficult recipe to follow but I regard natural movement and dynamic stability as primary therapeutic objectives rather than something to pursue after a patient can produce an isolated transverse abdominus contraction. This trajectory from ‘isolation to integration’ is a hallmark of conventional rehabilitation dogma.

In working with patients with chronic low back pain it has become apparent that their ability to produce and experience relaxed pain-free movement is intoxicating and compelling – an inspired basis for compliance and motivation. This observation is consistent with the clinical research of Peter O’Sullivan. Dull unrelenting transverse abdominus isolation is doomed, and unless monitored intently, is likely to exacerbate rigid motor control  and patterns of muscular excess observed in chronic low back pain.

What is natural movement and how do I prescribe it?

Natural movement and functional strength have become very fashionable. Functional is the latest fitness and rehabilitation industry credential. Gyms that ripped out olympic lifting platforms are now scrambling to cater for purportedly functional training. These settings and associated exercise product are inappropriate for patients trying to move beyond chronic low back pain. Before undertaking movement rehabilitation the patient first needs strategies to disrupt the cycle of exacerbation and recurrence – so called ‘spine-sparing’ interventions advocated by spinal bio-mechanist and lecturer Stuart McGill. 

Once this cycle has been disrupted and some basic re-patterning and awareness occurred then simple movement practices can be implemented. Many of these have been tweaked and adapted from traditional movement traditions and are easily adapted to clinical and home-based settings. These movement practices promote the integrated embodiment through the experience of continuity, coordination and relaxation. These practices are often simple and make hidden tensions transparent. Movement practices are individualised, improvised and responsive, based on patient assessment across all dimensions.

A patients immersion into any of these pathways is a start but the project of pain-free embodiment is usually ongoing and requires variety. Helping patients build a pallet of practices and approaches that include relaxation, strength, power, flexibility, coordination and improvisation is necessary and realistic.

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