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    • 06 JUN 16
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    Recognizing Back Pain

    Knowing and Explaining Your Back Pain to Your Doctor

    We may put our bodies at risk as we carry out our daily activities. One body part which we need to care more for would be our lower backs. While this specific area used to be limber and flexible, it may tend to degenerate as we age. This is why we need to be more aware of the risks which may come with the chores and daily errands which we fulfill. In case we experience some levels of pain, we must also know how the sensation must be explained to the physician.

    It’s additionally helpful to have a physician whom you can readily count on, in case some forms of pain occur. Make sure the Chiropractor or specialist you’ll get in touch with, would also have a wide scope of expertise to ensure your needs will be completely covered.

    Did you know there are major trigger points which may contribute to your back pain? Knowing how exactly your back must be aligned, would pave lots information so you may be further aware of how you must move around and additionally care for your back.

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    It has been suggested that low back pain is an inevitable result of walking upright (Harari). As the force of gravity acts upon the skeleton and its muscular and ligamentous armature, it is distributed via the fascia into three dimensions. Myers (2013) talks of an internal cohesion- compression of the body where it is both collapsing in on itself and pushing out from itself in a constant state of equilibrium, a concept called ‘tensegrity’. Tensegrity is seen nowhere better than in the spine.


    If the spine were a straight, rigid stick it wouldn’t be able to compensate for the multiple forces acting upon it. Therefore it is specifically arranged in a series of curves (cervical and lumbar lordosis and thoracic kyphosis). Along with the spinal discs, these curves are essential for shock absorption and are maintained by an interblend of muscles and ligaments that fire up in cyclical sequences.


    Even though all of the spinal vertebrae are designed to move, the spine also demonstrates specialization in its movement patterns ,allowing us to exploit our three dimensions. The direction of movement is mainly determined by the orientation of the spinal “facet joints”: forward and backwards movements (flexion and extension) from the low back, sideways from the neck (side bending) and rotation from the thoracic spine (although this is limited by the ribs). The other important movement is a type of nodding backwards and forwards which is translated through the sacroiliac joints (nutation and counter-nutation).


    Layered on top of the vertebrae are a series of ligaments that are strong and specialized to resist directional forces They again can be a source of pain and may develop “trigger points”. On top of the ligaments is a complex but beautiful system of muscles. The deepest spinal muscles are used to make minute adjustments in vertebral orientation (rotatores, interspinalis and intertransversalis).


    Then the multifidus with its large and strong fibers bridging several vertebrae at once and helping to maintain posture.


    The next layer of muscles connects the vertebrae to another from one to six segments upwards. This is the erector spinae and it is divided into three columns. Moving outwards from the center it forms a “wing like” structure – spinalis, longissimus and iliocostalis. The erector spinae don’t really keep the spine erect (that’s the job of the psoas and the multifidus) but they do extend the spine from a flexed position.


    Side-bending is mainly performed by the quadratus lumborum muscles. Arranged over these muscles we have broader, flatter and more superficial muscles such as the latissimus dorsi.


    Added to all this hardware is the software that the brain uses to co-ordinate and sequence movement. All of the above structures feed information to the brain in a constant stream affording it orientation (proprioception), as well as force and direction (velocity). The brain responds by organizing movement sequences hierarchically in functional units. These functional units mainly consist of a prime mover (agonist), an opposing muscle force (antagonist) and other muscles that either fix the local joint (fixators) or help the prime mover (synergists).


    The body tends to shut down around pain to avoid further noxious stimuli. Part of the way it does this is by using trigger points. For example, the erector spinae, multifidus, iliopsoas, quadratus lumborum, piriformis, rectus abdominus and hamstring muscles often manifest trigger points in patients with disc problems. Similarly, the gluteus medius muscle often ‘switches-off’ and develops trigger points around sacro-iliac problems.


    So here’s a brief overview of how, why and where trigger points develop in the above structures and their connection to lower back pain:




    The multifidus muscles help to take pressure off the vertebral discs so that our body weight can be well distributed along the spine. Image Credit

    The multifidus muscle has a deeper and more superficial arrangement. It is intimately involved with most types of LBP and often manifests trigger points. Because the muscles are so deep you need to use firm pressure to work on these trigger points.


    Erector Spinae

    Interestingly and contrary to what some of us have been taught the erector spinae don’t hold the spine erect! Most fibers are electrically silent during postural work (Kippers 1984). This muscle group is designed to activate during extension from flexion, i.e. standing upright from bending forward. The erector spinae has three divisions each of which may manifest a trigger point. According to Simons, Travell, and Simons, individual pain patterns of several trigger points that refer pain to the Lumbosacral region may blend into each other.



    The piriformis takes its origin from the lower part of the sacrum but it also often gets involved with the protective patterns. It has been suggested that when the piriformis muscle gets tight, it can compress the sciatic nerve, or even the blood vessels to the nerve, (vaso nervorum) which can lead to (pseudo) sciatica. Remember that 17% of people have a sciatic nerve that runs through the piriformis muscle.


    Rectus Abdominus

    The rectus is an antagonist to the multifidus muscle and may either get involved with LBP due to reciprocal inhibition or it may be a source of LBP itself. It is also interesting to note that trigger points in the lower rectus may also cause diarrhea and symptoms mimicking diverticulosis or gynecological disease.

    We have often found that treating trigger points in the rectus adds the finishing touch in some patients. Often it can also be the reason why the lower back trigger points don’t stay released.











    Mechanically, the iliopsoas has an intimate relationship with maintaining the lumbar spinal lordosis and is often involved in mechanical LBP, but that is not the whole story. In her book The Vital Psoas, Jo Ann Staugaard- Jones also describes the physical, emotional and spiritual aspects of the iliopsoas. Staugaard-Jones talks of the iliopsoas as two distinct muscles: the psoas major (one of the deepest core muscles) and the ilaicus.

    The psoas, she maintains, is the only muscle that connects the upper body to the lower (spine to legs) and integrates deeply with the nerve and energy systems: “It is enervated by the lumbar nerve complex (lower back) and when released, helps energize subtle body systems!”


    Glutes, Piriformis and Hamstrings

    Along with the tight glutes and piriformis the lower back muscles tend to form a triangle of tight, spastic and fatigued tissues. Postural changes also cause tension in the hamstring muscles, which also often manifests trigger points and can ache after exercise.



    We often find trigger points in the hamstring muscles associated with LBP. Sometimes this is a cause-and-effect relationship, from a trapped nerve (radiculopathy) in the spine (sciatica). In these cases not all of the information/trophic input reaches the muscle fibers and the muscles may become tight and full of trigger points. The corollary is also true. Sometimes a tight hamstring will have a negative mechanical effect on the lower back.


    Quadratus Lumborum (Q/L)

    The myofacial pain maps for the Q/L tend to radiate into the pelvis even though the trigger points are higher in the spine. Taut bands in the quadratus lumborum muscle can contribute to scoliosis. The Q/L is often involved in any disc pathology literally bending the patient to one side (especially in the morning).


    Levator Ani – Sacral Pain

    The levator ani muscle consists of the pubococcygeus and the iliococcygeus muscles. Together with the coccygeus muscle, these muscles form the pelvic diaphragm (the muscular floor of the pelvis). Trigger points in the levator ani muscle are often implicated in low back pain syndromes.


    Soleus – Sacral Pain

    The soleus is a “classic” example of a trigger point whose myofascial pain map is remote from the origin. The soleus is deep in the calf, yet in some cases a trigger point in the soleus can refer pain to the coccyx area. We have seen this personally and it is fascinating how treating this trigger point relieves the low back pain.

    Considering all the possible forms of back pain, it would then be necessary for you to know how the sensation must be exactly explained to your physician and Chiropractor. This way, your chosen specialist would have a better means of diagnosing and treating your condition.

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    An experienced chiropractor has tips to help you get the care you need at your next appointment

    Student-Loan-Forgiveness-for-NursesFor those battling “invisible pain” such as fibromyalgia, CRPS (complex regions pain syndrome),RSD (reflex sympathetic dystrophy), diabetic neuropathy or chronic pain after cancer treatment, accurately conveying the location, frequency and depth of the discomfort can be particularly challenging and emotionally taxing.


    If you or a loved one are combatting short-term (acute) pain or a neuropathy (pain lasting 12 weeks or longer), I’d like to offer my own simple tools to help you accurately convey the unique characteristics of your pain so that the most effective treatment protocol can be set into motion.


    You may wish to bring this article to your next doctor visit and go over each of the key pain description points I’ve outlined below.


    I hope your doctor will ask you these questions, but if not, you can act as your own pain advocate and offer this information.


    Pain symptoms are personal, unique–and subjective. (What Joe describes as “unbearable pain” may be considered “pretty unpleasant pain” to Mike). Over the years, I developed my own “pain diagnostic” conversation with patients to help my team and I understand what, where, when and how much pain patients are feeling.


    I’ve outlined key points below:

    Timing Matters

    This is key to a proper diagnosis. Don’t assume we know you’ve battled this pain for a year, a month or a decade.

    Spell it out:

    1. I’ve had this pain for _________________.
    2. How frequently and how long does it last?
    3. What ignites (flare) or lessens your pain and for how long?


    Location, Location, Location

    Doctors may instruct you to mark the area/s where your pain is concentrated. They may also ask you to note a difference between pain that is on the surface and pain that is under the surface.

    How Bad is Your Pain – A Measurement Tool


    Image Credit

    Most referring physicians, regardless of their medical specialty, use a simple 1 to 10 point pain scale, so I stick with this to keep everyone on the same page.


    No Pain

    0 – Pain-free

    Manageable Pain

    1 – Pain is very mild, barely noticeable. Most of the time you don’t think about it.

    2 – Minor pain. Annoying and may have occasional stronger twinges.

    3 – Pain is noticeable and distracting, however, you can get used to it and adapt.

    Moderate Pain—Disrupts normal daily living activities

    4 – Moderate pain. If you are deeply involved in an activity, it can be ignored for a period of time, but is still distracting.

    5 – Moderately strong pain. It can’t be ignored for more than a few minutes, but you still can manage to work or participate in some social activities.

    6 – Moderately strong pain that interferes with normal daily activities. Difficulty concentrating.

    Severe Pain—Disabling; debilitating, reduces daily quality of life, cannot live independently

    7– Severe pain that dominates your senses and significantly limits your ability to perform normal daily activities or maintain social relationships. Interferes with sleep.

    8– Intense pain. Physical activity is severely limited. Conversing requires great effort.

    9– Excruciating pain. Unable to converse. Crying out and/or moaning uncontrollably.

    10– Unspeakable pain. Bedridden and possibly delirious. Mobility may be compromised.


    Create a Pain Journal

    If you come prepared with all this information, your time with the doctor can be better spent focusing on next steps and a treatment plan, rather than a lengthy Q & A review of the information provided here.

    More importantly, addressing these issues in advance will ensure your doctor receives up-to-date, higher quality information.


    It’s worthwhile to know the tendencies by which your back may be at risk of. Aside from ensuring you’ll be in a much better disposition to care for your back, it would also be necessary to know how your pain must be explained to your doctor. For patients who have persistent cases of pain, it’s even more important to secure scheduled appointments with a practitioner.

    Integrated Pain Management has the goal to minimize their patients need for medication and reconcile their bodily functions. This way, individuals may productively resume to their lifestyle and enjoy their hobbies. They take on a personal and thorough approach so patients will be ensured of customized solutions.



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