Two primary sources of chronic back pain are muscular hypertonicity
(resulting in joint compression and possible nerve impingement) and lactic
acid buildup in hypertonic muscles (creating nociceptor irritation). Improper
or insufficient movement, trauma, and/or postural habits lead to (and result
from) chronic muscular hypertonicity and soreness.
This essay presents a radical departure from the conventional viewpoint of
clinical therapeutics. It states that to resolve back pain often requires
neither strengthening nor stretching, neither mechanical skeletal adjustment
nor application of electrical stimulation, heat or cold, neither muscle relaxants
nor surgery. In many cases, to resolve back pain requires nothing more than improving the
link between kinesthetic awareness and motor control, the benefits of which, in
some cases, might be augmented by soft-tissue manipulation.
Both traditional and newer treatment methods are discussed.
INTRODUCTION
The conventional understanding of muscular back pain is that it results
from traumatic injury, poor posture, genetic (mis)endowment, old age, or
from "insidious causes". Pain is often attributed to strain,
sprain, or facet joint damage or irritation.
In cases of traumatic injury, such as whiplash or a lifting injury,
a strain, sprain, or joint damage may in fact have occurred. In many cases,
however, pain reflects chronic muscular hypertonicity following injury
or subsequent to long-term stress. Lactic acid buildup and tissue irritation
follow.
Two basic conditions contribute to lactic acid build-up in muscle and
thus, to back pain:
- chronic muscular hypertonicity
- disorganization of the fascial network (connective tissue)
Chronic Muscular Hypertonicity
Chronic muscular hypertonicity may result from long-term performance
of repetitive motion (e.g., at work); from long-term emotional distress
(i.e., heightened tension), or from trauma (reflexive retraction from pain
upon injury that persists through healing). In all cases, muscular tension
begins as a momentary response and becomes chronic/automatic through habituation.
It often persists even during sleep.
Whether muscular hypertonicity results from pain (i.e., from guarding
against pain) or produces it, the results are the same: reduced movement,
decreased circulation, and accumulation of lactic acid in the involved
muscle tissue.
Habituated contraction can accumulate in "layers" (with multiple
episodes of heightened tension), often to crisis proportions, as often
happens with back pain.
Habitually tight muscles interfere with movement and interfere with
their muscular antagonists; fatigue, stiffness, and soreness result.
Chronic co-contraction of extensors and flexors is one mechanism by
which unresolved muscular tension persists. When the extensors and flexors
of the trunk co-contract, they shorten the spine and compress the intervertebral
discs; this is a common origin of disc degeneration and radiculopathy.
Whether muscular hypertonicity arises from physical or emotional origin,
the result is the same: lactic acid build-up and joint compression.
Disorganization of the Fascia
The fascia is the fibrous matrix that
gives shape and tensile strength to tissue; in muscle, fascia is called,
"myofascia". In soft tissue, fascia grows or shrinks according
to functional demand. This logic of growth-by-demand creates a pattern
of organization visible as the physical person; it also imprints stress
and trauma upon the fascial system, present as patterns of disorganization
-- contraction and restricted movement. The fascia is thus an organ of
memory, whether of healthy function or of dysfunction, as well as of tissue integrity.
The consequences of trauma -- heightened muscular tension, pain, and
fatigue -- may thus persist due to disorganization of the fascia. Long-term
consequences may include crises of spasm and long-term joint degeneration.
SUMMARY OF INTRODUCTION
Two basic conditions, muscular hypertonicity
and fascial disorganization, can account for many or most cases of chronic
back pain.
METHODS OF TREATMENT
We discuss four basic areas of praxis for the treatment of back pain:
- physical therapy modalities
- chiropractic manipulation
- somatic education
- myofascial release techniques
In physical therapy, therapeutic exercise, heat, electrical stimulation,
and massage are the usual modalities used to treat back pain.
In chiropractic manipulation, adjustments of vertebral placement shift
patterns of compression communicated through the skeletal system.
In somatic education, accelerated sensory-motor learning retrains the
central nervous system (CNS) to alleviate muscular hypertonicity.
In myofascial release techniques, soft-tissue manipulation frees adhesions
and restriction in the myofascial system.
Physical Therapy Modalities
Therapeutic Exercise, Heat, Ice, Electrical Stimulation,
and Massage, Strengthening and Stretching
Therapeutic exercises may, if properly taught, supervised, and practiced
by the patient, improve sensory awareness and voluntary control over muscular
tension. Although the rationale behind therapeutic exercises is usually
to strengthen muscles, a more precise understanding is that it improves
coordination and control of muscles, upon which strength depends. Such
exercises, performed ballistically, produce little benefit and may increase pain and spasticity. To produce the most benefit, they must be performed
slowly, smoothly, and with due respect for the patient's comfort level
(to avoid guarding against pain by tightening further).
Moist heat, applied to the affected area, increases circulation and induces
relaxation.
Application of ice can numb pain and, through a rebound of circulation to restore warmth to an area, result in removal of lactic acid.
These three approaches are therefore effective ways to flush lactic acid
from the soft tissues, and that is the primary benefit. These modalities
are therefore palliative; hypertonicity tends to return.
Electrical stimulation may produce temporary relaxation and mask pain;
by inducing increased awareness of the hypertonic muscles, it may also
indirectly improve voluntary control over muscular tension.
Muscular activity and massage move fluids from the soft tissues into
the bloodstream and lymphatic system, through pumping action.
Strengthening and stretching, a mainstay of physical therapy, overlook that the primary locus of control of muscles is not muscles, themselves, but the brain, and that, by means of postural reflexes. Postural reflexes are inherently present but subject to modification by learning (of sensory awareness and movement); they are commonly triggered by injuries (pain) and stress and may become habituated, as in the case of common back pain. Strengthening and stretching produce temporary benefits, but usually with results slow in coming. Strengthening exercises may improve the ability to contract muscles but do not equally improve the ability to relax muscles, which often results increased muscle tone, muscle fatigue and pain; as a counter-measure, stretching is commonly applied, but without regard for the brain-level control mechanisms, so that conditioned muscular tension commonly reappears. For that reason, back pain is considered difficult to resolve.
Skeletal Adjustments
Bone movement and position reflect muscular pulls and the lines
of stress communicated through the musculature and fascial system.
Sense receptors in joints communicate bone movement to the CNS, which
in turn controls muscular tensions associated with posture.
Thus, movement and sensation form a feedback loop for the maintenance
of postural alignment.
For bone displacement maintained by muscular tensions of recent development (i.e.,
superficially-habituated), skeletal adjustments can be sufficient to interrupt
postural reactions to injury and bring relief.
Muscular tensions of long duration (i.e., more-deeply habituated status), may reappear
after skeletal adjustments. In such cases, the relief is only temporary; and subsequent and frequent adjustments may be needed indefinitely to maintain physical comfort.
Somatic Education
Somatic education addresses the sensory-motor aspect of the CNS to reduce
muscular hypertonicity. It is indicated where residual tension persists
after injured tissue has healed or where hypertonicity returns after treatment
by conventional methods.
Three forms of somatic education will be discussed, here:
- conventional postural training
- movement training
- assisted pandiculation
Examples of somatic education include Proprioceptive Neuromuscular Facilitation
(PNF), The Alexander Technique®, The Trager Approach® (M. Trager, M.D.), Feldenkrais® Functional
Integration (M. Feldenkrais, Ph.D.), Aston Patterning® (J. Aston), Rolfing® Movement (I.P. Rolf, Ph.D.), and Hanna Somatic Education® (T. Hanna, Ph.D.). All of these
methods use the client/patient's capacity for learning to bring the resting
state of hypertonic muscles closer to true rest (zero tonus).
Conventional Postural Training
Conventional postural training teaches patients to establish a neutral
spine position in movement and to maintain it in all activity. Patients
thus limit their movement and tend to maintain protective holding patterns
in the musculature ("guarding"). Guarding leads to conditioning
into chronic patterns of tension, and patients tend to remain fearful about
their injury.
An alternative to this choice is to maintain "normal spinal curves".
The fallacy of this approach is that there exist "normal spinal curves";
the spine is inherently a flexible structure whose curves change according
to load, position, and emotional tension. This fallacy extends to the use
of "lumbar supports".
Movement Education
Movement education seeks to develop balanced agonist/antagonist muscular
coordination throughout the body. Where agonist overpowers antagonist (where
reciprocal inhibition is interfered with by chronic hypertonicity), postural
aberrations result.
For example, in individuals who typically stand with knees locked and
feet and legs splayed apart, abductors and the external rotators of the
thighs have overpowered the adductors and internal rotators. The pelvis
is thrust forward, as a result, the rib cage falls back, and the head,
forward. Such a position accentuates the spinal curves and adds strain
to the musculature of the neck and thoracic spine.
Movement education optimally uses balanced movements that "reprogram"
control of agonist/antagonist muscle pairs. The patterns of movement thus
cultivated permit release of more habituated tensions, including those
of injury-guarding and emotional distress. As better-balanced movement
patterns develop, compensatory muscular responses are less necessary; muscular
tensions redistribute themselves and abate. Lactic acid concentration and
pain decrease.
Assisted Pandiculation
Pandiculation is an instinctual behavior
that purges residual tension from the neuromuscular system and arouses the sensory-motor nervous system. Found among all vertebrates, the action commonly precedes moving from rest into activity, visible as the proverbial, "stretching." Assisted pandiculation systematically triggers the effects of pandiculation through a kind of
"eccentric, active- resistive range of motion" maneuver; this
maneuver produces sufficient sensory awareness of the involved areas to
induce rapid sensory-motor learning. Assisted pandiculation produces a
nearly instantaneous, stable reduction of habitual hypertonicity that can,
if necessary, be maintained with a few minutes of patterned movement a
day. It may be the fastest method known for bringing involuntary (habituated)
muscular hypertonicity under voluntary control.
As of this writing, there is only one system of movement education known
which uses assisted pandiculation: Hanna Somatic Education.
To be most effective, somatic education must include the whole body
(since the neuro-musculo-skeletal system operates as a whole to maintain
balance in the gravitational field). All of the methods named above cultivate
relaxed or easy balance (grace) in movement and at rest, though some work
more quickly than others.
Myofascial Release Techniques
Myofascial release techniques free restrictions of the fascial
network that have developed through injury or through growth under chronic
muscular tension.
Certain varieties concentrate on symptomatic relief and direct their
processes accordingly.
The technique developed by Ida P. Rolf, Ph.D. ("Structural Integration")
addresses the body as a whole via a systematic, 10-session system that
concentrates on improving overall physiological functioning, apart from
consideration of symptoms.
Structural Integration works by guiding the fascia into a pattern of
distribution that more nearly approximates its anatomical ideals, as
indicated by bony landmarks and joint structure and function.
This process balances the agonist/antagonist pairs, distributes tensional
forces in the myofascia, and so allows the core of the body to relax and
open. Structural Integration differs from myofascial release, per se, by
its systematic approach to postural alignment and balance in movement,
and in its recognition of the functional relationship of hard and soft
tissues in relation to the gravitational field.
In cases of chronic "poor posture," problems can usually be
found in the myofascial system, e.g., twists, thickening, displacement from
normal position, etc. Consequently, agonist/antagonist muscle pulls are
imprecisely matched and impaired, leading to irregularities of movement,
impaired coordination, muscle weakness, and poor postural support. As stated
above, chronic pain, fatigue, and postural breakdown accompany myofascial
distortions. Neuromuscular compensations, including decreased mobility
and unbalanced alignment, ensue.
For example, the shoulder and hip joints are related. In walking, they
move contralaterally; at rest, they counterbalance each other: As one hip
moves forward, the shoulder above it tends to move backward as a postural
reflex. The torso connects the two girdles, hip and shoulder. Compensatory
shifts of these girdles twist or distort the spine and rib cage. The combination
of a twist, shears, and muscle tension adds stress to the whole torso.
For that reason, when treating back pain, the establishment of a
dynamically balanced and freely functional neutral spine position requires
free movement and reciprocal coordination of the shoulder the hip girdles.
The technique of Structural Integration involves (1), placing the displaced
part near its position of optimal relationship with its neighboring parts,
(2) manually restraining the local myofascia,
where disordered, and simultaneously, (3) having the patient/client move
the part in a way approximating normal movement. The combination of movement
and tissue-restraint repositions the myofascia to a better approximation
of the norm.
SUMMARY
Though varying in etiology and degree of severity, back pain
has a common feature: build-up of lactic acid in muscle tissue and resulting
irritation. Muscular hypertonicity and postural distortions create pain,
facet joint irritation, and radiculopathy. Disorganization of the fascial
network restricts movement and triggers postural responses to overcome
those restrictions.
Hypertonicity may result from injury (trauma reflex), persistent emotional
responses, repetitive movements, habitual poor posture, and/or prolonged
immobilization.
Treatment modalities addressing those mechanisms -- through the disciplines
of physical therapy, chiropractic, somatic education, and myofascial release
-- have been discussed.
ACKNOWLEDGEMENT
I pay my respect to the late Thomas Hanna, Ph.D., whose writings and
personal instruction provided a structure for my personal somatic explorations
and for my work with others.
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