Rationale for Treatment

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Sacroiliac strains do exist As stated by the authors of Posture and Pain, "Because the normal range of motion of the joint is small, it takes very little more to be excessive. A tension sufficient to cause ligamentous strain may not appear on x-ray" (10).

Treatment varies from the conservative approach of nothing other than application of support in the form of a belt, corset, or brace to the use of sophisticated mobilization techniques.

In all probability, most sacroiliac strains are the result of undue tension on the ligaments without any displacement. There is no way of knowing how many cases are never brought to professional attention but clear up spontaneously. Very often, application of a belt or some other support gives immediate relief. This response to immobilization is a strong indication of a strain only.

Opinions vary widely with respect to the need for mobilization. In some cases, it may be the treatment of choice and appropriate; in others, it may be unnecessary and unwarranted. If a belt does not offer relief but mobilization does, it is plausible that a minor displacement was corrected by the manipulation. Many individuals will be helped by use of a support after the mobilization treatment. A person who is subject to recurrent attacks is in greater need of a support to protect the joint from becoming too mobile as compared to a person who has had a simple strain.

The sacroiliac joint is supported by strong ligaments. No muscles cross directly over the joint to support it There would be no useful function for elastic, contractile tissue (e.g., muscle) to act on a joint that has almost no movement. Weakness or tightness of muscles elsewhere, however, can affect the sacroiliac joint. When motion is restricted in an adjacent area (e.g., the back or the hip joints), stress on the sacroiliac joints is increased during any forward-bending movement.

Sacroiliac strain in subjects with flat-back posture and tight hamstrings tends to be more common among men than among women. On the other hand, sacroiliac strain in subjects with a lordosis is found more often among women than among men. Sacroiliac strain may be bilateral but more often is unilateral. There may be more pain in sitting than in standing or walking. The strain can be brought on by sitting in unsupported flexion of the lumbosacral region (e.g., sitting on the floor tailor fashion, squatting, or sitting on a chair or a sofa that is too deep from front to back).

Usually, there is tenderness over the affected sacroil-iac area. There also may be diffuse, not easily defined pain through the pelvis, buttock and into the thigh. Pain may be referred to the lower abdomen and groin area, and at times, there may be associated sciatic symptoms. In some cases, there is pain on hip flexion.

For immobilization with a belt, commercial belts are usually available and adequate for men. For women, it is more difficult to keep a belt from riding up out of a position of support.

These photographs show a panty girdle with a strap approximately 3 inches wide attached to the girdle with three strips of Velcro. One piece is attached at the center posteriorly, and one is attached on either side an-terolaterally. The strap stays in place both in sitting and in standing. If the subject is wearing a corset for a low back problem, the strap can be attached to that garment.

FACET SLIPPING

The joints or facets that connect one vertebra with another may show abnormal deviations of alignment, which is referred to a facet slipping. Conceivably, a facet slipping may occur at the limit of range in flexion or in hyperextension. As a fault in hyperextension, it may result from a sudden movement in that direction or from a severe, persistent lumbar lordosis; the latter has been seen on radiographs (24). The vertebral interspaces are diminished, and the lordosis is so marked that the force of compression has caused the joint structures to give way and permit the "overriding" of one facet on another.

The suddenness of onset, acuteness of pain, and absence of previous neuromuscular symptoms suggest that some cases of acute low back pain may be a result of facet slipping. A patient's description of "hearing a click, like something slipping out of place," suggests that an alignment fault has occurred. Usually, these incidents are only of momentary duration, and as such, they are not confirmed by radiography. The diagnosis is established, necessarily, based on subjective rather than objective findings.

The movement of the body and the direction of stress denote the direction of the alignment fault. Most often, it occurs during flexion, and the patient reports being unable to straighten.

When the stress results from hyperextension movements, the so-called "catch in the back" may be a muscle spasm, or it may involve excessive motion in the form of facet slipping.

The faults of alignment and mobility that result in excessive joint motion are the basic factors to be considered in correcting or preventing faults of this type.

COCCYALGIA

Coccyalgia or coccygodynia refers to pain in the coccyx or neighboring area. Numerous factors, including trauma, are responsible for coccyalgia. Faulty position of the body may have no relation to the onset of symptoms but may result secondarily and become an important factor.

One who has persistent coccyalgia tends to sit in a very erect position, with hyperextension (i.e., lordosis) of the spine in an effort to avoid undue pressure on the painful coccyx. Years of sitting in such a position can result in tightness in the low back and weakness of the gluteus maximus muscles.

Conservative treatment consists of providing some padding for the coccyx by use of a corset, which is worn low to hold the buttocks close together. Preferably, this corset has back laces that cross over and tighten by lateral straps.

The corset should be tightened with the patient standing. The gluteal muscles thus form a padding for the coccyx in the sitting position. A soft pad may be incorporated into the corset as well. Pain may be alleviated by this simple procedure.

KYPHOTIC-LORDOTIC POSTURE

Pour groups of muscles support the pelvis in anteroposterior alignment. The low back extensors pull upward on the pelvis posteriorly, the hamstrings pull downward posteriorly, the abdominal muscles pull upward anteriorly, and the hip flexors pull downward anteriorly. With good muscle balance, the pelvis is maintained in good alignment. With muscle imbalance, the pelvis tilts anteriorly or posteriorly. With anterior pelvic tilt, the low back arches forward into a position of lordosis. In this position, there is undue compression posteriorly on the vertebrae and the articulating facets, and undue tension on the anterior longitudinal ligament in the lumbar area.

Kyphotic-lordotic posture.

Hip flexion with the trunk inclined forward.

The muscle imbalances that are associated with an anterior tilt may include all or some of the following: weak anterior abdominal muscles, tight hip flexor muscles (chiefly the iliopsoas), tight low back muscles and weak hip extensor muscles.

The figures above show these muscle imbalances. Figure A shows a marked lordosis. The lordosis shown in Figure B would also be marked if the subject were to assume an erect posture. When all four muscle groups are involved, correction of the anterior pelvic tilt requires strengthening of the anterior abdominal muscles and hip extensors and stretching of the tight low back and hip flexor muscles. Any one of the above may be a primary factor, but the tight low back and weak hip extensor muscles are least likely to be the primary cause.

Frank Ober stated, "It is well known that a lordotic spine may be a painful spine, but this, of course, is not true in every case" (25). Farni and Trueman have emphasized the common association of increased lumbar lordosis and low back pain (26). Some individuals with a lordosis complain of low back pain, whereas others with a more severe lordosis may not complain of any pain. A lordosis may be habitual, but if the muscles of the back are flexible enough that position can be changed from time to time, symptoms may not develop. A back so tight that the lordotic position is fixed, however, tends to be a painful back regardless of the body position.

The best index in regard to a painful low back is not the degree of lordosis or other mechanical defect visible on examination of alignment. Rather, the extent of muscle tightness maintains a fixed anteroposterior alignment, and the extent of muscle weakness allows the faulty position to occur and to persist.

WEAK ANTERIOR ABDOMINAL MUSCLES

Weakness of anterior abdominal muscles allows the pelvis to tilt forward. These muscles are incapable of exerting the upward pull on the pelvis that is needed to help maintain a good alignment. As the pelvis tilts forward, the low back is drawn into a position of lordosis.

The individual with a lordosis in which abdominal muscle weakness is the main problem usually complains of pain across the low back. During the early stages, this pain is described as fatigue; later, it is described as an ache, which may or may not progress to being acutely painful.

Pain is usually worse at the end of day and is relieved by recumbency to such an extent that, after a night's rest, the individual may be free of symptoms. Sleeping on a firm mattress allows the back to flatten, and this change from the lordotic position gives relief and comfort to the patient.

The back may be eased in sitting by resting against the back of the chair and avoiding the erect sitting position, which tends to arch the low back. Relief of pain can also come from the use of a proper support to help correct the faulty alignment and relieve the strain on the weak abdominal muscles. (The William's Flexion Brace and the Goldthwait Brace were designed to support the abdomen and correct the lordosis.) (See also p. 226.)

When marked weakness exists, the patient should start an exercise program and continue using the support for a period of time while working to build muscle strength. This advice is contrary to the often-repeated admonition that the muscles will get weaker if a support is used. Weakness from wearing a support will occur only if the patient does not exercise to build up the muscles. Use of the support helps to maintain alignment and to relieve stretch and strain of the weak muscles until they regain strength through exercise.

Abdominal muscle weakness is present for varying lengths of time following pregnancy. Being cognizant of this fact, physicians often give patients a list of exercises intended to strengthen these muscles. Unfortunately, these lists have included sit-ups and double-leg-raising exercises, which should not be given when the abdominal muscles are very weak. (See pp. 209, 215, and 216 for exercises to strengthen abdominal muscles.)

With back extensor or hip flexor tightness, it is necessary to treat these muscles to restore normal length before the abdominals can be expected to function optimally. (See pp. 381 and 242, 243 for stretching exercises.)

TIGHT ONE-JOINT HIP FLEXORS (CHIEFLY ILIOPSOAS)

Tight one-joint hip flexors cause an anterior tilt of the pelvis in standing. The low back goes into a lordosis as the subject stands erect. Occasionally, a subject inclines forward from the hips, avoiding an erect position that would result in a marked lordosis. (See Figs A & B on page 59.)

This subject had marked lightness in the hip flexors, which limited hip joint extension. The subject also had limitation of back extension. To push up from the table, movement had to take place at the knee joint. As an exercise, this movement would not be appropriate for this subject.

The severity of the lordosis depends directly on the extent of the hip flexor tightness. Stress on the low back in the lordotic position is often relieved by giving in to the tight hip flexors. In standing, this is accomplished by bending the knees slightly. In sitting, the hips are flexed, and the hip flexors are slack. Some people can sit for long periods of time without pain or discomfort but have pain when standing for brief periods. In such cases, these patients should be examined for hip flexor shortness. Lying on the back or on the side with the hips and knees flexed relaxes the pull of the tight hip flexors on the low back. Patients often seek these means to relieve pain in the back—and legitimately so during the acute stage. The problem, however, is that giving in to the tightness by flexing the hips in these various positions aggravates the underlying problem, permitting further adaptive shortening of the very muscles that are causing the problem.

When knees are bent to relieve discomfort in the back, an effort should be made not to bend them mote than necessary. After the hip flexors are stretched through appropriate exercises, it is not necessary to flex the hips and knees to be comfortable when lying on the back.

In the back-lying position with the hips flexed enough to allow the back to flatten, the patient will be more comfortable on a firm mattress than on a soft one. On a soft mattress, the pelvis sinks down and tilts anteriorly, causing a lordotic position of the low back.

Lying on the abdomen is not tolerated, because the tight hip flexors hold the back in a lordotic position. The prone position, however, can be made comfortable by placing a firm pillow directly under the abdomen to help flatten the low back and allow slight flexion of the hips.

A back support can provide some relief from a painful back that is held in a lordosis by tight hip flexors, but it cannot help to stretch the tight hip flexors, (See p. 381 for hip flexor stretching exercises and pp. 215, 216 and 381 for exercises to strengthen lower abdominal muscles.)

Trying to accomplish stretching of tight hip flexors by occasional periods of treatment is difficult if the patient's occupation requires staying in a sitting position. Adaptive hip flexor shortening is a common problem lor patients in wheelchairs. The patient must realize that it may be necessary to stretch the tight muscles daily to counteract the effects of a continuous sitting position.

TIGHT TWO-JOINT HIP FLEXORS

The degree of tightness that is usually seen in the two-joint hip flexors (i.e., rectus femoris and tensor fasciae latae) does not cause a lordosis in standing. The reason is that the muscles are not elongated over the knee joint when the knee is straight. (Tightness would have to be severe to be tight over both joints.)

Tightness causes a lordosis in the kneeling position. When someone complains that only the kneeling position causes pain in the low back, it is important to examine for two-joint hip flexor shortness. (See hip flexor length test, pp. 376-380.)

Sometimes tightness is very marked, and stretching should be done in a manner that does not put stress on the patella during knee flexion. It is recommended that the knee be placed in flexion, as shown in Figure A, so the patella can ride over the knee joint before starting further stretching. Proceed to stretch the hip flexors by pulling upward and inward with the lower abdominal muscles to posteriorly tilt the pelvis and extend the hip joint, as shown in Figure B.

TIGHT LOW BACK MUSCLES

Tight low back muscles cause an anterior tilt of the pelvis, and they hold the low back in a position of lordosis. These muscles cross over joints of the vertebral column, but they do not cross over another joint at which the muscles can give in to the tightness. Regardless of body position, the low back will remain in a degree of extension that corresponds to the degree of tightness of these muscles. In forward bending, the low back remains in an anterior curve and does not straighten. (See p. 175.)

For cases in which tightness of the low back muscles is a primary factor, pain may be chronic but often has an acute onset. Pain is increased by—and tends to have its onset in—movement rather than standing or sitting positions. The problem tends to be more common among men than among women.

Pain may be relieved or made worse by recumbency. Relief of pain in recumbency results from removing part of the strain caused by the movement or muscle action in maintaining the upright position. Increase of pain in recumbency occurs if the body weight in the supine position imposes a strain on the back muscles. During bed rest in the acute stage, some relief is obtained by giving in to the back by putting a small roll under it. This roll should conform to the contour of and give support to the low back. The pressure against the low back offers some relief. When a back support in the form of a corset or a brace is indicated, it sometimes is advisable to use the support when recumbent as well as when weight bearing.

In addition to the relief that comes from restriction of motion, pain is relieved by pressure from the support against the low back. Steel stays in back supports (see illustration on page 62) should be bent in to conform to the back, and a pad may be added if it gives additional comfort.

anchoring the adhesive to it, there is less chance of irritation from the tape.

People with a lordosis often complain of having a "weak back." The term is used because of the feeling of aching and fatigue in the low back and because of the inability to lift heavy objects without pain. This type of back is mechanically weak and inefficient because of the faulty alignment, but the low back muscles are not weak. The connotation of the word weak is that the back muscles are in need of strengthening. On the contrary, these muscles are strong, overdeveloped and short Back extension exercises are contraindicated.

The lordosis posture with tight low back muscles tends to give rise to pain in movement or position. Change of body position does not give relief if the tightness is marked. The back remains immobilized in faulty alignment by the muscle tightness whether the patient is standing, sitting or lying.

Years ago, it was not uncommon to find muscle tightness in the low back. Environmental and cultural factors affect postural habits. Low back muscle tightness sufficient to hold the low back in a fixed anterior curve, however, is no longer a common finding. It is possible that sitting at work, sitting in cars, and the emphasis on exercises that flex the spine (especially knee-bent sit-ups) have reversed these problems—and created some new ones—with respect to low back pain.

WEAK HIP EXTENSOR MUSCLES

Hip extensors consist of the one-joint gluteus maximus and the two-joint hamstring muscles. Weakness of these muscles is seldom found as the primary factor in anterior pelvic tilt but when found in conjunction with hip flexor shortness or abdominal muscle weakness, the associated pelvic tilt and lordosis tend to be more exaggerated than if the hip extensor weakness were not present.

Slight to moderate weakness of the gluteus maximus and hamstring muscles will allow the pelvis to tilt forward in the standing position. Weakness of the hamstrings alone would not affect the pelvic position to the same extent. Marked weakness or paralysis of the hip extensors presents the opposite picture. With extreme

The relief of pain that may accompany immobiliza-tion—and the fear of repeating the movement that brought on the acute attack—may have so impressed the patient that there will be reluctance to cooperate in treatment to restore movement Recovery depends on cooperation, and this will not be obtained unless the patient understands the procedure.

Giving in to the lordotic position and supporting the back in that position for the relief of pain should not be the goal of treatment Stretching the low back muscles to restore normal flexibility and building up the abdominal muscle strength are long-term goals. (See p. 242 for stretching the low back and pp. 215 and 216 for strengthening the lower abdominal muscles.)

Below are several forms of abdominal and back supports.

Adhesive strapping may be used for those needing only temporary support or until a more rigid support can be obtained.

A piece of muslin is placed under the abdomen with the patient in the prone position. The adhesive strips are anchored to the muslin on either side. A series of thin, wooden applicators, placed on an additional patch of adhesive, is then placed over the tape on the low back.

The applicators are broken by gentle pressure so that they conform to the apex of the curve in the low back, and then several more strips of adhesive are applied. The muslin acts as an abdominal support, and by weakness, the only stable position of the hips is obtained by displacing the pelvis forward and the upper trunk backward (as in sway-back posture), distributing the body weight over the center of gravity with the hip joint locked in extension and the pelvis in posterior tilt. (See p. 434 for a comparable example of marked hip abductor weakness.)

Hamstring weakness more often results from overstretching than from lack of exercise. The first step in strengthening these muscles is to avoid the movements or positions that overstretch them. Exercises to strengthen the hamstrings can then be added in the form of resisted knee flexion with the hip flexed or prone knee flexion with the hip extended. In the prone position, the knee should not be flexed to the extent that this two-joint muscle is placed in an ineffective, shortened position. The optimal position for strengthening and test ing is at an angle of approximately 50° to 70° of knee flexion in the prone position. (See p. 384 for normal hamstring length and pp. 418 and 419 for optimal test and exercise positions.)

In the standing position, the hamstring muscles may feel taut whether they are stretched or short. On postural examination, this tautness usually is interpreted as tight hamstrings, resulting in treatment to stretch the hamstrings as a corrective measure. When this tautness is associated with stretched hamstrings, however, stretching is con-traindicated as a treatment. Accurate testing for hamstring length as described in Chapter 7 is necessary for an accurate diagnosis and prescription of therapeutic exercises. Faulty postural alignment is indicative of hamstring length: A lordosis and hyperextended knees suggest the presence of stretched hamstrings, but flat-back and sway-back postures suggest the presence of short hamstrings.

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Dealing With Back Pain

Dealing With Back Pain

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