Traumatic LBP aside, there are (6) possible categories to organize LBP contributors. Classical orthopedic exams would likely not rule out these:
(#1) Neural & (#2) Motor contributors:
While it might seem overly obvious that nerve malfunction or injury would contribute to LBP, I propose that other neural contributors likely prevail. Sub-threshold Micro-traumas (STMT, Dean 2016) represent accumulated tissue damages associated with a specific action that do not stimulate a symptomatic response (sub-clinical), however it does stimulate a tissue repair response that is repeatedly unsuccessful. STMT may occur due to intrinsic or acquired mechanical economy; path of least resistance (PoLR, Dean 2016), poor instruction, lack of instruction, occupational or sport demands, or other habits and biases. Failure to address STMT while focusing on clinic symptoms, such as pain, does not deal with the causative faulty motor patterns. These underlying motor patterns are certainly dysfunctional if practiced over and over in ADLs, and worse with sports, especially competitive sports when efforts, forces, and demands are highest, and while recovery time and recovery programs are neglected or not considered important. Many athletes are under-recovered, not over-trained.
Poorly performing motor patterns are developed for a variety of reasons; however, regardless of the reason, an improved motor pattern that fires ‘around’ or ‘instead of’ the problem motor pattern will not use the faulty pattern nor the symptomatic tissue within it… HA! So, it is as simple as prescribing an improved ‘fixed’, ‘re-sequenced’ motor pattern the same day, and your patient is back in action, and in total AWE! The micro-traumas develop in a motor pattern (movement sequence) in which the employment of it does not match the mechanical capabilities intrinsic to it. An example: the lumbar spine is not designed for rotation, but rather for stability and transmitting rotational power across it when the origin of the rotation is the TLJ (thoracolumbar junction.) If rotational power is fed toward the lumbar spine, it will be unable to deal with it as the TLJ can. Lumbar spine micro-traumas will cause inflammation, eventual scarring, and degenerative changes. Continued feeding of rotation to the lumbar spine will eventually emerge as clinical pain. The patient must learn to employ TLJ rotation, and abandon lumbar spine rotation simultaneously. Remember: symptomatic compensation to associated dysfunction (SCAD.)
Poorly performing motor patterns commonly do not originate in distal motor systems, they are continuous with myofascial Slings (Vleeming, 2012) that cross the mid line, and between the upper and lower body simultaneously. Ground-Force-Reaction (GFR) is the body’s proprioceptive baseline, therefore, all motor malfunction, Faulty Motor Patterns (FMP), occur because Core Neutral (CN, McKechnie 2006) is not established and the distal motor pattern is not grounded into the Core first… the sequence is broken. Quality GFR must be established first, and prior to sequencing distal motor patterns. For example: a tennis player’s ‘ready’ stance-base is corrupt: narrow footing, legs are straight, and racquet is down… waiting at the baseline… the player is unprepared to return the ball. The ball arrives within stroke proximity, but since Core Neutral is not automatically established, the player must react with an enormous amount of sudden torque and hit the ball any way possible (defensive, in tennis this is called being ‘late’) rather than being ‘ready’ in a wide, sprung, lowered Core Neutral stance, racquet up,… and when the ball is approaching, the player sets-up by running into the ball with a well-prepped swing set-up (offensive.)
Surgical scarring and traumatic scarring is disorganized non-vascularized hard-tissue networks that cause adjacent muscle to become involved in a motor pattern for which they were not designed, or can eliminate motor patterns and joint function in the lower back. Since scarring is not innervated, it can’t contribute to quality proprioceptive feedback (absent GTO and MS.) I see a lot of surgical failure patients complaining of low back pain. If I had a chance to see them before a decision for surgery, these patients could have experienced a much better quality of life (QOL) a long time ago. Remember to ask about scars during history taking.
During diagnosing and prescribing, focus on motor patterns and the slings that they are embedded within, along with GFR to understand the FMP and the patient’s symptoms. SCAD is likely the best place to start. Build the best possible relationship with your LBP patients by exploring motor patterns because ‘pain is not the only problem.’
LBP Blog General information
These articles intend to (1) re-evaluate the prevailing clinical practices thought to manage low back ‘pain’, (2) submit and debate novel low back ‘pain’ contributors and mechanisms, (3) meet patient expectations & satisfaction and clinically meaningful results, (4) recommend a conservative non-surgical course of care to over-ride ‘pain’ instantly, and (5) restore ADLs and patient confidence on the first visit at low cost. This article has a companion podcast.
Dr. Dean Bio
Forester Dean is a chiropractic and physiotherapy sports medicine doctor practicing in Los Angeles, California. Dr. Dean is a lifetime athlete, and currently teaches tennis, track, boxing, yoga. The Core X System™ Campus flagship location was opened by Dr. Dean in 2020. www.preformancecxs.org
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